rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
3705,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2018-07-19,580,D,0,1,W6NO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify an incapacitated resident's medical power of attorney when a change in condition occurred. This affected one (1) of twenty-two (22) sampled residents. Resident identifier: #65. Facility census: 96. Findings included: a) Resident #65 The medical record was reviewed on 07/17/18. On Thursday, 07/13/18, a physician progress notes [REDACTED]. At that time, the physician assessed her with [MEDICAL CONDITION]. On Friday, 07/14/18, the physician ordered blood work and a chest x-ray to be completed on 07/16/18,. He also wrote a new order to begin [MEDICATION NAME] (an antibiotic) 100 milligrams twice daily for seven (7) days. On 07/16/18 the chest x-ray confirmed the [DIAGNOSES REDACTED]. Further review of the medical record found no evidence that this incapacitated resident's medical power of attorney (MPOA) was notified of this change in condition. An interview was conducted with the assistant director of nursing (ADON) on 07/18/18 at 1:45 p.m. She reviewed the medical record, then looked in several offices for evidence of MPOA notification. At 2:00 p.m. on 07/18/18, the ADON agreed there was no evidence that the MPOA was notified of the resident's change of condition. The ADON said the MPOA should have been notified of the change in condition at the time of occurrence. She said she instructed the resident's nurse to contact the MPOA right away to notify her of the [DIAGNOSES REDACTED].",2020-09-01
3706,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2018-07-19,583,E,0,1,W6NO11,"Based on observation and staff interview, the facility failed to protect the personal privacy of residents including medical and health information. Various resident treatments were left unattended in a bath/shower room. Personal identifiers including resident names, medications, and other health information were viewable by anyone. This was a random observation. Resident identifiers: #27, #31, and #48. Facility census: 79. Findings included: a) Observation A random observation, on 07/16/18 at 11:15 am, on the East B Hall, revealed Resident #27, #31, and #48's treatments were left unsecured and unattended in the bath/shower room. Each treatment container had a pharmacy label that contained the following information: -Resident's name -Medication prescribed -Physician's name b) Interview An interview with Certified Nursing Assistant (CNA) #101, on 07/16/18 at 11:20 AM, revealed the resident's treatments should be locked up in the treatment carts. The CNA stated she would immediately remove them.",2020-09-01
3707,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2018-07-19,584,E,0,1,W6NO11,"Based on observation and staff interview, the facility failed to provide maintenance services for six (6) of forty-three (43) rooms observed during the Long Term Care Survey Process (LTCSP). The issues identified included dining and lounge rooms with scratched doors with missing paint. Room identifiers: A-Dining Room, B-Dining Room, C-Dining Room, D-Dining Room, A/C Lounge, and B/D Lounge. Facility census: 79. Findings included: a) Observations The following observations were made on 07/16/18 and 07/17/18 during the LTCSP: -A Dining Room-The doors were scratched and missing paint. -B Dining Room-The doors were scratched and missing paint. -C Dining Room-The doors were scratched and missing paint. -D Dining Room-The doors were scratched and missing paint. -A/C Lounge-The doors were scratched and missing paint. -B/D Lounge-The doors were scratched and missing paint. b) Interview An interview with the Building Grounds Manager (BGM), on 07/18/18 at 10:00 AM, revealed maintenance rounds are done monthly. The BGM stated since the building is old and big it is hard to keep up with all the needs. The BGM stated he was aware of the dining room doors being scratched and would paint them as soon as possible.",2020-09-01
3708,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2018-07-19,623,D,0,1,W6NO11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record information it was determined the facility had not notified the ombudsman of the transfer of resident #54 to the hospital. This was evident for 1 of 2 residents reviewed for hospitalization s. Census 79. Findings included: a) Resident #54 A review of the medical record on 07/17/18 indicted the resident was hospitalized from [DATE] to 05/16/18. Documentation in the record did not show that the Ombudsman had been notified the resident had been sent to the hospital. This is required per the regulation. 07/19/18 08:28 AM surveyor met with ADON to see if the Ombudsman had been notified of the transfer. She was unable to locate any info in the chart regarding the Ombudsman. She stated they fill out a document in the record and then it is faxed to the ombudsman's office. She attempted to locate the fax form. after this discussion. At 9:05 a.m. she returned to the surveyor and stated they were not able to locate any documentation that showed info was sent to the ombudsman.,2020-09-01
3709,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2018-07-19,641,E,0,1,W6NO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to complete an accurate minimum data set (MDS) assessment for three (3) of twenty-two (22) assessments reviewed during the investigation process of the survey. The MDS for Resident #30, #34, and #61 did not accurately reflect the use of restraints and for Resident #37 there was a wrong [DIAGNOSES REDACTED]. Resident identifier: #30, #34, #37 and #61. Facility census: 79. Findings include a) Resident #30 A review of the medical record for Resident #30 on 07/18/18 revealed the quarterly mimimum data set (MDS) with an assessment reference date (ARD) of 05/02/18 was inaccurately coded for the use of limb restraints in Section P. A review of the current physician's orders for (MONTH) (YEAR) and care plan had no indication this resident required limb restraints. In an interview with the assistant director of nursing (ADON) on 07/18/18 at 1:41PM, reported Resident #30 had a bed alarm discontinued in (MONTH) 2012 and that this facility does not use limb restraints, she also verified this section of the MDS had been coded incorrectly. b) Resident #34 A review of the medical record for Resident #34 on 07/18/18 revealed the quarterly MDS with an assessment reference date (ARD) of 05/17/18 was inaccurately coded for use of a trunk restraint in Section P. A review of the current physician's orders for (MONTH) (YEAR) and care plan had no indication this resident required a trunk restraint. In an interview with the ADON on 07/18/18 at 3:03 PM, reported Resident #34 did not require a trunk restraint and this section of the MDS had been coded incorrectly. c) Resident #37 A review of the medial record for Resident #37 on 07/19/18 revalued the quarterly MDS with an ARD of 05/181/8 was inaccurately coded for the [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. In an interview with Employee #48, registered nurse (RN) on 07/19/18 at 10:39 AM, verified the [DIAGNOSES REDACTED].#37. d) Resident #61 07/17/18 09:44 AM the surveyor noted the use of a limb restraint used less than daily on the Minimum Data Set (MDS). Current physician orders did not have any restraints listed in the current course of treatment. Additionally the care plan did not have a problem with restrain use incorportated or interventions in place. Discussion with MDS staff 07/18/18 10:22 a.m.revealed the MDS had been marked in error to show a limb restraint. The resident does not use any restraints at this time. She corrected it and showed surveyor the error correction after surveyor intervention.",2020-09-01
3710,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2018-07-19,657,D,0,1,W6NO11,"Based on medical record review and staff interview the facility failed to revise and evaluate the effectiveness of the interventions for fall prevention for Resident # 45 and Resident #57 needed accident interventions revised. This was true for two (2) of three (3) residents reviewed for the care area of accidents reviewed during the survey process. Resident identifiers: #45 and #57. Facility census: 79. Findings include a) Resident #45 A review of the medical record review on 07/18/18 revealed the care plan had not been revised to include falls Further review of the Incident and Accident reports revealed this resident had sustained three (3) falls without injury on 02/25/18, 05/03/18 and 06/21/18. A review of the minimum data set (MDS) with an assessment reference date (ARD) of 05/22/18 was coded to reflect this resident had two (2) or more falls without injury since prior assessment. In an interview with the assistant director of nursing (ADON) on 07/18/18 at 3:45 PM, verified the care plan had not been revised to include the three (3) falls nor did the revision indicate an evaluation of the effectiveness of interventions for the preventions of falls for Resident #45. b) Resident #57 A review of he medical record review on 07/18/18 revealed the care plan had not been revised to include interventions of unsteadiness for Resident #57 while walking. This unsteadiness has contributed to her bumping into furniture, which causes bruising to her lower extremities. A review of the Incident and Accident reports included an incident on 05/16/18 where Resident #57 had a bruise on her left hip from bumping into furniture due to her unsteadiness while walking. In an interview with Employee #48, registered nurse (RN) on 07/18/18 11:11 AM verified she had not revised the care plan for Resident # 57 to include her occasionally bumping into furniture due to unsteadiness while walking.",2020-09-01
3711,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2018-07-19,684,D,0,1,W6NO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to follow physician orders [REDACTED]. Resident identifiers: #1, #40, and #48. Facility census: 79. Findings include: a) Resident #1 A random observation of Resident #1, on 07/18/18 at 8:15 AM, revealed the Resident's fall mat was off the floor beside the bed and leaned against the wall. The Resident was in bed at the time of the observation. An interview with Licensed Practical Nurse (LPN) #151, on 07/18/18 at 8:20 AM, revealed the fall mat was supposed to be on the floor beside Resident #1's bed due to a high fall risk. A review of Resident #1's physician orders, on 07/18/18 at 8:30 AM, revealed an order for [REDACTED].>A review of the Care Plan was conducted on 07/18/18 at 8:55 AM. The Care Plan, with a creation date of 01/12/18, contained the problem the Resident is at risk for falls related to impaired mobility due to lower extremity impairment, history of fracture, antidepressant medications, and noncompliance with asking for assistance with the intervention mat at bedside. b.) A review of the medical record, for Resident #40, on 07/17/18, revealed a physician's orders [REDACTED]. Observations made on 07/17/18, at 11:02, Resident #40 was having difficulty maneuvering the wheelchair. During an interview, on 07/17/18, at 11:35 AM, Resident #40 stated he wanted his walker back. An interview with LPN#153, on 07/18/18, at 11:05 AM revealed Resident #40 uses a wheelchair to Propel on and off the unit and not the forward wheeled walker as ordered by the physician. c) Resident #48 The medical record was reviewed on 07/18/18. Pertinent [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The physician's orders [REDACTED]. Nursing staff documented they administered the [MEDICATION NAME] daily at 8:00 p.m. in July, (YEAR). Review of the vital signs record found that the blood pressure and pulse rate were assessed most days in July, (YEAR), at 8:00 a.m. and at 4:00 p.m. daily. However, on (MONTH) 02, 07, 12 the blood pressure and pulse rate were assessed only once daily at 4:00 p.m. On (MONTH) 13 and 14 the blood pressure and pulse rate were assessed only once daily at 8:00 a.m. The medical record was silent every day in (MONTH) (YEAR) for any blood pressure or pulse assessments just prior to the administration of the nightly [MEDICATION NAME]. This failure to check the the blood pressure and pulse would therefore make it impossible for the nurse to know whether to hold or to administer this medication. Review of the pulse rate assessments found that the pulse rate was less than 60 beats per minute on the following dates and times: -07/01/18 at 8:00 a.m., pulse rate 55 beats per minute. -07/05/18 at 8:00 a.m., pulse rate 58 beats per minute. -07/11/18 at 8:00 a.m., pulse rate 58 beats per minute. -07/11/18 at 4:00 p.m., pulse rate 56 beats per minute. -07/16/18 at 2:41 p.m., pulse rate 56 beats per minute. An interview was conducted with the assistant director of nursing (ADON) on 07/18/18 at 1:05 p.m. She said staff obtained the vital signs twice daily at 8:00 a.m. and 4:00 p.m. in July. She admitted that a few days they were taken only once per day. She said their computer system does not remind the nurse to assess the blood pressure and pulse prior to administering the 8:00 p.m. [MEDICATION NAME], and to hold the medication if the systolic was less that 60 mm/hg or the pulse rate less than 60 beats per minute. She acknowledged that the nurse would not know whether to hold or administer the [MEDICATION NAME] at 8:00 p.m. if the nurse did not assess the vital signs at that time.",2020-09-01
3712,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2018-07-19,689,E,0,1,W6NO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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, used needles were not properly disposed of, and a shower room contained hygiene products, chemicals, and razors, accessible to anyone. This practice had the potential to affect more than a limited number of residents. Facility census: 79. Findings include: a) Medication Cart An observation during medication administration of the West C Hall, on 07/18/18 at 7:55 AM, revealed the medication cart was unlocked while in the hallway. The cart was unlocked, unattended, and out of sight of any staff from 7:55 AM until 8:00 AM. The cart contained the medications for the C Hall residents. An interview with Licensed Practical Nurse (LPN) #151, on 07/18/18 at 8:05 AM, revealed the medication cart should always be locked when not in sight of the nurse. The LPN stated she usually locks the cart but was nervous being watched by the surveyor. b) Needles An observation of the West C Hall, on 07/18/18 at 8:15 AM, revealed the medication cart's sharps disposal box had two (2) used insulin syringe needles and three (3) used insulin lancets lying on top. An interview with Licensed Practical Nurse (LPN) #151, on 07/18/18 at 8:17 AM, revealed the used needles and lancets should have been placed inside the sharps disposal box and not on top. c) Shower Room A random observation of the East B Hall Shower Room, on 07/16/18 at 11:15 AM, revealed the room did not have a lock and contained the following unsecured items: -One (1) container of TNT Foaming Disinfectant Cleaner-Staphylocidal-Salmonellacidal, Pseudomonicidal, Virucidal with the warning Caution-Keep out of reach of children-Hazard to Humans and Domestic Animals-Causes moderate eye damage. -Two (2) containers of McKesson Anti-Perspirant with the warning Keep out of reach of children. -Two (2) containers of McKesson Shaving Cream with the warning Keep out of reach of children. -One (1) container of [MEDICATION NAME] 100,000 Units. -One (1) container of [MEDICATION NAME] Blue Medicated Shampoo with the warning Keep out of reach of children. -One (1) container of [MEDICATION NAME] 2% Shampoo. -One (1) container of [MEDICATION NAME] Topical Suspension 2.5%. -Two (2) capped shaving razors. An interview with Certified Nursing Assistant (CNA) #101, on 07/16/18 at 11:15 AM, revealed the shower room should always be locked. The CNA stated the bathing products, razors, and chemicals should not be accessible to any residents.",2020-09-01
3713,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2018-07-19,880,D,0,1,W6NO11,"Based on observation and staff interview, the facility failed to prevent the development and transmission of disease and infection. A nurse conducting a dressing change did not change their gloves after removing a soiled dressing, apply gloves before opening wound care supplies, or supply a barrier on the table being used for wound care supplies. This practice affected one (1) of two (2) residents observed for dressing changes. Resident identifier: #54. Facility census: 79. Findings included: a) Observation An observation of Licensed Practical Nurse (LPN) #151, on 07/18/18 at 2:30 PM, revealed the nurse was conducting a dressing change of Resident #54's pressure ulcer to his hip and coccyx area. The LPN first put on a pair of gloves, handled her work keys, removed a soiled dressing, then continued to clean the resident's wound without donning a new pair of gloves. The LPN then removed the gloves and opened a foam dressing with her bare hands. The dressing was handled in several places before the LPN placed the dressing on the table. The table did not have a barrier. The LPN then donned a new pair of gloves and attempted to place the foam dressing from the table onto the Resident. b) Interview An interview with LPN #151, on 07/18 at 2:45 PM, revealed the LPN usually changes gloves during every step of the dressing change but was nervous and forgot to do so. The LPN stated she never lays a barrier on the table while conducting dressing changes. The LPN stated she should have put gloves on before touching the dressing used on the Resident.",2020-09-01
3714,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2019-09-12,583,D,0,1,K00K11,"Based on observation, staff interview and policy review, the facility failed to honor Resident #70's privacy while administering an insulin injection. This was a random opportunity for discovery. Resident identifier: #70. Facility census: 75. Findings included: On 09/10/19 at 11:16 a.m. observation was made of an insulin injection being administered to Resident # 70 in an in the hallway of the C-Wing unit. Licensed Practical Nurse (LPN) #34 administered an insulin injection to Resident #70 while he was setting in a geriatric chair in the hallway with other residents, staff, and visitors present. LPN #34 raised Resident #70's shirt and administered the insulin in his left abdomen without providing any privacy or moving the Resident to his room. During an interview on 09/10/19 at 3:10 p.m., Charge Nurse #34 confirmed the insulin injection should not have been administered in the hallway and the resident should have been taken into his room for privacy. Review of the facility's Medication Administration policy on 09/11/19 at 2:12 p.m. revealed a guideline for injections that stated: All Injections should be administered in the resident's room.",2020-09-01
3715,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2019-09-12,600,E,0,1,K00K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and resident interview, the facility failed to ensure Resident's #21, #22, #11 and #66 were free from psychological and verbal abuse. The facility failed to prevent Resident #51 from wandering into other resident's rooms/space; cursing at others; taking, touching, and rummaging through other resident's personal property thus evoking resident to resident altercations, evoking fear and unrest among other residents. This was true for five (5) of six (6) residents reviewed for resident to resident altercations. Resident identifiers: #51, #22, #66, #21, and #11. Facility census: 75. Findings included: a) Resident #51 Review of the resident's most recent Minimum Data Set (MDS) with an assessment reference date of 08/02/19, coded the resident as having physical behavior (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) as having occurred 4 to 6 times in the last 7 days but less than daily. Verbal behavior directed towards other, threatening screaming, and cursing as having occurred daily in the last 7 days. b) Observation of Resident #51 behaviors During the initial tour as well as meal observation on 09/09/19 at 12:53 PM, Resident #51 was wandering around the A wing dining room. The following are observations on the day of entrance to the facility. --09/09/19 12:53 PM, R 51 wandering around A wing. --09/09/19 12:56 PM, R 51 trying to touch items on other resident's trays. Resident #51 stands over Resident #11 as R #11 is trying to eat her lunch. --09/09/19 12:58 PM, Employee #22, LPN, redirected R #51 from R #11's food --09/09/19 1:07, R #51 going in and out of rooms on A North wing. R #51 removed water pitcher from Room A-5. R #51 placed the water pitcher on a blue recliner that was covered in plastic protective cover that was located in the hallway. R #51 rummaged in all drawers in room A-2. R #51 then lies in bed in A-2. R #51 goes in and out of that room. There was no staff supervision during these observations. --09/09/19 1:08 PM, R #51 goes into room A-1. Employee #115, housekeeper, was cleaning in Room A-1. Employee #115 told Resident #51 that the room was not her room and that the resident could not be in that room. Employee #115 remained cleaning Room A-1 while Resident #51 was still in Room A-1. --09/09/19 01:09 PM, R #51 went into Room A-3. There were no staff on hall that were visible. R #51 was rummaging in Room A-3. --09/09/19 01:10 PM, R #51 went back into Room A-1. Employee #22, LPN, was present A North Hall. Employee #22 walked by R #51 while she was in Room A-1. Employee #22 did not stop R #51 from going into room that was not hers nor did Employee #22 try to redirect R #51 from rummaging and touching items in Room A-1. --09/09/19 1:11 PM, R #51 entered Room A-2. R #51 and was rummaging on all 3 beds in that are in Room A-3. Employee #22 was still present on A North wing. Employee #22 did not attempt to stop nor redirect Resident #51. --09/09/19 1:12 PM, Resident #51 entered Room A-3. R #51 was rummaging on bed. This is not R #51's room. Employee #22, LP, walked off of the hall of A North wing and exited through the doors at the nurses' station. Employee #22 did not intervene nor redirect R #51 from being in Room A-3. During this time, R #51, was rummaging on another bed. R #51 was touching and adjusting 2 of the 3 beds in this room. --09/09/19 01:13 PM, Resident #51 went back into Room A-3. R #51 walked around the room and touched nightstands, bed, and chairs. --09/09/19 01:14 PM, Resident #51 went back into Room A-3. Employee #22 walked in and out of this room while R #51 was wandering in this room. This is not Resident #51's room. Employee #22 did not redirect or try to have resident exit room. R #51 exited the room at 1:15 pm. --09/09/19 01:19 PM, R #51 entered Room A-1. R #51 was rummaging through this room. --09/09/19 01:20 PM, Resident #51 entered Room A-2 and walked around the room touching various items in this room, including items that are not hers. --09/09/19 01:21 PM, Resident entered Room A-2. This is R #51's room; however, R #51 was going through other resident items that on the other beds in this room. --09/09/19 01:24 PM, Resident #51 was going in and out of rooms on A east. Employee #22, LPN did see Resident #51, but did not redirect the resident. --09/09/19 04:06 PM, Resident #51 was cursing another resident (Resident #1). This occurred in the hallway at the entrance door to A East. Resident #51 was telling Resident #1 that he is going to hell. --09/09/19 04:09 PM, Resident #51 entered Room A-11. --09/09/19 04:15 PM, Resident #51 was touching Resident #18's drink. Resident #18 stated you go on. leave that alone. c) Nursing notes found in Resident #51's medical record. A record review of Resident #51 noted the following nurses notes (copied as written in resident's chart) --6/2/19 at 15:46: Resident cont. (continued) to be restless and agitated this shift. PRN ( as needed) [MEDICATION NAME] given per order with minimal effect. Resident has been going into resident #9180 room causing that resident to become agitated. Multiple attempts at redirection, but behavior cont. throughout this shift. Placed on cb for physician review charge nurse notified of prn [MEDICATION NAME] and resident change in behavior, notified POA/family [NAME] of residents change in behavior. Family noted to increase in agitation, as they attempted an outing with resident when she became extremely agitated and attempted to bite daughter. Pre restraint form completed. --6/3/19 at 20:00: Resident receives prn [MEDICATION NAME] having agitation, yelling very loud in dayroom as staff attempts to redirect her from going in other resident's rooms, she refuses snacks and drinks as staff attempts to change her mood with snack or drink, resident spills pop on her bed leaving the near full can on her blankets. --6/5/19 at 00:02: Resident receives her prn [MEDICATION NAME] for agitation as she has been offered snacks and drinks to shift her mood, while she was in the bathroom, she removed her depends, torn up depends but into the three bathroom sinks and turned the water on, staff has returned her to her bed several times since 10:30 pm and hopefully she will be able to get some rest having received her prn. --6/5/19 at 01:32: Resident up out of bed, ambulates to bathroom on A North, spends a little time in the bathroom, water could be heard running, staff goes to the bathroom to find all three sinks with paper towels and toilet paper in the sink with the water running strong and water overflowing into the floor, one toilet plugged up also, night shift staff clean up bathroom, resident currently in room lying on bed as if asleep. --6/5/19 at 21:41: Resident agitated, shouting at staff. PRN [MEDICATION NAME] given at 730 pm. Is currently asleep in her bed. --6/6/19 at 12:25: Night shift charge nurse reported concerns about (name of resident) and her recent worsening of behaviors, her increase incidents of behaviors, such as wandering, taking items from others, screaming at staff, making false accusations, plugging up the toilet and sink, tearing dressing off her arm. (Psychiatric Physician name) ask us to consult with (Attending Physician name), and to do medical work up such as labs and ua. Notified (attending physician) of the above concerns and he plans to see (resident) on his visit tomorrow. --6/8/19 at 20:00: Resident receives prn [MEDICATION NAME] for aggression, as we were unable to change her mood by offering snacks, drinks or restroom needs, she had returned to the bathroom and was found with wet towels in the sink and the water running, she has been pacing and can be heard repeating herself, she speaks hateful when staff attempts to move her away from the bathroom sink or away from another resident as she stands in their personal space. --6/9/19 at 20:20: Resident receives pen [MEDICATION NAME] for aggression, she can be heard talking hateful as staff attempts to redirect her away from other residents, she is not concerned with a snack or drink this writer offers a drink and she will say 'I don't want it', she had been following staff into other resident's room as staff is assisting other resident's to bed, she stands in the doorway talking to herself, when staff asks her to leave or the resident of the room asks her to leave she becomes hateful in her response by the time staff walks her out of the room she is fitful and returns to the same place as if she intends to do what she wants. --6/11/19 at 06:31: Resident given PRN [MEDICATION NAME] at HS for agitation. Rsdt (Resident) walking very quickly down the halls, clenching fists and yelling, 'I'm leaving, I'm leaving.' Slept through night and woke up at appx 5 am and picked off scabbed areas on lower R (right) arm. Areas cleaned and dry dressings applied and also covered with long sleeve. --6/11/19 at 23:00: Resident received prn [MEDICATION NAME] for aggression, being unable to calm self, uncooperative to accept sandwich or drink, she has been yelling very loud paces hallways is returned to unit per staff and continues to be loud. --6/15/19 at 11:40: Resident given PRN [MEDICATION NAME] 1mg d/t increased agitation; and [MEDICATION NAME] 50 mg, Tylenol 650 mg po d/t increased pain. Resident increased pacing and crying at this time. Resident having moments of yelling. --6/17/19 at 20:00: Resident receives prn [MEDICATION NAME] for anxiety as drinks and snacks does not seem to help improve her mood, she continues to pace, repeat herself and speaks of leaving. --6/20/19 at 20:15: Resident received prn [MEDICATION NAME] for agitation, staff unable to improve her mood with drinks or snacks, she is loud at intervals repeats herself, paces and argumentative. --6/21/19 at 06:17: Resident agitated this evening, yelling at staff, stating that she wants to leave, walking very quickly up and down the halls. Unable to redirect with snack. PRN [MEDICATION NAME] given at 8pm. --6/22/19 at 06:04: Resident very agitated, picking at scabs on her arm and saying she wants to 'get out of here and never coming back.' Attempts to redirect her with a snack and juice are unsuccessful. PRN [MEDICATION NAME] given per MD order. --7/4/19 at 09:08: Resident ambulating in hallway, agitated. yelling at staff. Uncooperative with care. Multiple attempts at Redirection unsuccessful. Prn med given with success. --7/5/19 at 20:46: HSW (health services worker) stated that resident has been turning on all the sinks, yelling at residents in the hallway, saying, 'it hurts, I've got to get out of here!' Unable to redirect her. Gave her a PRN [MEDICATION NAME] for her agitation . --7/9/19 at 10:00: Resident was getting into trash and other resident's belongings. Pacing back and forth. Redirection unsuccessful. [MEDICATION NAME] 1mg po given per order. --7/11/19 at 20:00: Received prn [MEDICATION NAME] for anxiety, after receiving a drink, snack, and encouraged to sit down, but continued pacing and yelling. --7/12/19 at 10:44: Resident pacing and yelling. Drinks and food offered with no success. PRN [MEDICATION NAME] given as ordered. --7/15/19 at 20:15: Resident had got into the big trash can on the unit and got a diaper out of it and rubbed her face with it getting BM on her nose and cheek. Hsw cleaned it off and redirected resident to stay out of the trash can. --7/15/19 at 20:30: Resident receives prn [MEDICATION NAME] for agitation after receiving snacks and a drink and being unable to improve her mood, she has been unable to verbally redirect as she paces the unit, goes in and out of other resident's rooms, she picked up a blanket belonging to another resident becomes more loud and argumentative when verbally redirected to return items, other residents become upset which has caused loud outburst on unit, she removes several pairs of depends off the cart, takes gloves out of the boxes on the wall, tears on the occupied sign that is on the staff's restroom door. --7/16/19 at 10:22: Resident was becoming more agitated, getting into other resident's belongings. Got resident # 9120 remote. Very uncooperative. [MEDICATION NAME] 1mg po given. --7/17/19 at 01:45: Resident had been asleep earlier but is now awake, assisted to bathroom, assisted back to bed but up gotten up self up out of bed and walking unit, going into other resident's rooms, becomes argumentative when verbally redirected by staff, encouraged to sit in chair on hall and would only sit for a brief period of time, received drink and snack but did not improve her mood, received [MEDICATION NAME] PRN PO (by mouth) for agitation. --7/17/19 at 20:15: Receives PRN PO [MEDICATION NAME] for agitation after resident's mood is unchanged by being offered snacks, drink, urged to sit down, or lay down, she has been pacing hallway and going into other resident's rooms. Some residents fuss at her to leave the room she then becomes loud, has a frown and stomps as she walks and talks as if angry, 'I'm leaving here, I'm not coming back' she repeats this phrase and as she continues this behavior. --7/19/19 06:27: Resident was given PRN [MEDICATION NAME] at HS d/t her behaviors. She was agitated, pacing the floor, yelling at others. Unable to distract resident by offering a snack or a drink. Took medications without incident. --7/21/19 at 20:00: Med prn for anxiety et pain. Pacing et worried expression. (et means and) --7/23/19 at 06:40: PRN [MEDICATION NAME] administered at 730pm, d/t resident being agitated, yelling at other residents, shouting, 'I have to leave!' Resident went to sleep appx 830 pm and slept well without further incident. --7/24/19 at 06:42: Resident was repeating, 'it hurts, it hurts. She was walking very quickly into other resident rooms, getting into the trash can in the hallway, turning on the sinks in the bathroom. Unable to distract rsdt with juice or snacks and wouldn't sit in the recliner. Administered PRN [MEDICATION NAME] for her agitation . --7/25/19 at 21:19: Resident was screaming at HSWs that were trying to calm her down, asking her to sit in the chair. HSW ( health service worker) reported that for the past few hours, rsdt has been going into the bathroom and turning on the sinks; digging in the trash, going into others rooms and messing with others belongings and picking at her arms. At 8pm, this nurse administered a PRN [MEDICATION NAME] to her, per MD order. --7/26/19 at 00:53: Resident awoke at approx 2400. She is very irritable, screaming at the HSW and running down the hall. She continuously entered bedrooms that weren't' her own, sitting on top of resident who were sleeping. Tried to redirect with a drink and a snack, but resident became louder and angrier. Administered a PRN [MEDICATION NAME] per MD order at this time --7/29/19 at 00:02: Resident pulling dirty briefs out of the trash. She is very upset, yelling at HSW, 'I've got to go, get out, get out!' Unable to redirect to recliner. Offered snack, but declined. Administered PRN [MEDICATION NAME] per MD order at this time. --7/30/19 at 16:30: This resident was getting anxious, pacing back and forth and going into other residents rooms. Redirection unsuccessful, would just get more agitated. [MEDICATION NAME] 1mg po given per order. 7/31/19 at 08:09: Resident ambulating up and down hallway. In and out of other resident rooms. screaming 'it hurts' Redirection unsuccessful. Prn [MEDICATION NAME] and anxiety med given with success. --8/3/19 at 06:51: Resident ambulating on the unit, yelling out, 'It hurts, it hurts.' --8/4/19 at 18:05: Resident was screaming in the hall 'he hit me he hit me' when I walked on the hall she was walking back to her unit holding her chest saying he hit me. Co resident was in the hallway in a wheelchair at the time. Resident has a reddened area on her mid sternal area with no bruising at this time. Vital signs within the resident's normal limits. Resident was removed from he area where she sat in the chair and calmed herself down. message left with POA, charge nurse notified. --8/5/19 at 00:16: rec'd resident anxious et pacing et loud. Routine meds given. stated pain in back but [MEDICATION NAME] is effective an hour later. Resting in bed by 9pm. No additional effects of incident earlier. --8/6/19 at 17:35: Resident has experienced a multitude of outbursts this shift, yelling at everyone in her line of site, cussing, and screaming at the top of her lungs without reason. Resident is also displaying increased agitation. Placed on concern board for MD. Will continue to monitor. --8/6/19 at 22:06: Resident has displayed increased agitation / anxiety during this HS med pass. She is going into the bathroom, turning on the faucets, then will start screaming profanities very loudly when attempting to redirect her. She shouts, 'I'm leaving. I'm going home, I'm not coming back, F--- you. Attempted to redirect resident with different snacks, juices, but with no success. Took HS medication without incident. --8/7/19 at 02:26: Resident ist still awake and has not been to sleep yet tonight. She has woken several other residents on the hall by screaming. Unable to get her into a recliner or into her bed. --8/7/19 at 15:15: This resident was standing out in the hall and resident #9152 rolled up to her and hit her in the stomach. Resident yelled out and resident #9152 rolled on down the hall in his w/c (wheelchair). --8/21/19 at 06:20: Resident seems agitated with staff and with other residents. Attempted to redirect her. Offered snack/drinks. Walked briskly through the halls and was saying, 'I'm leaving, I'm leaving. It hurts, hurts, hurts, blood, blood.' PRN [MEDICATION NAME] per MD order. --8/23/19 at 23:20: Resident was getting into the towels and wash clothes and had them in the floor in the bathroom. Going into other residents rooms while they are sleeping. [MEDICATION NAME] 1mg po given. --8/28/19 at 02:06: Resident with increased agitation, attempting to get into bed with other residents, yelling at Staff, attempts were made to help Resident get comfortable, PRN [MEDICATION NAME] administered, will continue to monitor. --8/30/19 at 04:34: Resident showing increased agitation during HS (at bedtime) med pass. She was going into other residents rooms, climbing into their beds, screaming out. Unable to redirect to a recliner or with a snack. PRN [MEDICATION NAME] administered per MD order. --08/31/19 at 06:35: Resident was very agitated, pacing the halls, yelling out at other residents. Offered a snack/drink; Unable to redirect at this time. PRN [MEDICATION NAME] given at this time, per MD order for agitation. --09/05/19 at 07:15: Resident already agitated this morning, yelling and pacing. PRN [MEDICATION NAME] and PRN [MEDICATION NAME] administered. Will continue to monitor. --09/05/19 at 11:55: Administered second dose of PRN [MEDICATION NAME] and PRN [MEDICATION NAME] due to the resident expressing being in pain as well as starting to pace and become agitated when being redirected. Will continue to monitor. --09/05/19 at 14:32: Reported by ADON (assistant director of nursing) to this nurse that resident was found lying in another resident's bed on C wing. No incident occurred. Resident redirected out of room / bed. Will continue to monitor. --09/06/19 at 14:12: Resident has not experiences any falls this shift. Anxiety and pain continues with PRN [MEDICATION NAME] and PRN [MEDICATION NAME] administered per order. Will continue to monitor. --09/09/19 at 14:33: Resident making false remarks saying another resident hit her. The resident she was accusing is sitting quietly in the hallway with her arms crossed. d) Incident/accident report On 08/04/19 the resident was screaming another resident hit her. Resident #51 was huddled against the wall. Residents were separated. On 08/07/19 the resident was again struck by another resident in the abdomen. e) Resident #22 On 09/09/19 at 1:16 PM, the resident expressed she had problems with Resident #51. She called Resident #51 by her first name and said, I have hit her but only once after she hit me first. I had to stand up for myself. She takes all my stuff. Resident #22 said Resident #51 wants to eat all her food. She goes into my room and takes my stuff. The resident said, Usually staff get my stuff from her and bring it back to my room. She said she didn't have to tell staff because they are all aware of Resident #22's behaviors and they don't do anything about her. Review of the Resident's most recent MDS with an ARD of 06/14/19 found the resident has a score of 15 on the Brief Interview for Mental Status (BIMS). A score of 15 is the highest score obtainable and indicates the Resident is cognitively intact. This resident was also coded as having no behavior problems. Review of the resident's medical record found no evidence of physical altercations between Resident #22 and Resident #51. On 09/10/19 at 1:15 PM, the Social Work Supervisor (SWS) #56 said she was unaware of a physical altercation between the 2 residents. SWS said, Resident #51, just wanders around the facility. The SWS was unaware Resident #51's behaviors were affecting other resident. f) Resident #66 On 09/09/19 at 1:01 PM, Resident #66 voiced a complaint regarding Resident #51. Resident #66 called Resident #51 by her first and last name and said she goes into my room all the time and takes my stuff. She takes the remote control for the television also. sometimes she scares me because of the way she curses and carries on all the time, I never know what she is going to do. Resident #66 said staff know what she is doing but they can't keep up with her. Review of the Resident's most recent MDS with an ARD of 08/13/19 found the resident has a score of 15 on the Brief Interview for Mental Status (BIMS). A score of 15 is the highest score obtainable and indicates the Resident is cognitively intact. This resident was also coded as having no behavior problems. On 09/10/19 at 1:15 PM, the Social Work Supervisor (SWS) #56 said, Resident #51, just wanders around the facility. The SWS was unaware Resident #51's behaviors were affecting other resident. An interview with the administrator on 09/11/19 at 10:56 AM revealed the administrator was unaware of any problems with Resident #51. On 09/10/19 at 11:52 AM, the surveyor spoke with DON regarding Resident #51. The DON stated that Resident #51 has a behavior tracking tool for her behaviors. The DON did note that Resident #51 was not care planned to go in and out of other resident rooms. The DON further noted that she was aware that several residents on A wing had voiced complaints regarding Resident #51's behaviors at meal times and when Resident #51 ambulates on the halls. During an interview with Employee #131, MDS nurse on 09/10/19 at 2:20 PM, Employee #131 stated that Resident #51 is not care planned for behavior of wandering and going in and out of other resident rooms. Moreover, Employee #131 reviewed the care plan the facility provided and stated that she did not see where wandering in resident rooms had been care planned. MDS #131 said she did not know about the residents behaviors, yet she was the same nurse that coded the resident as having the having physical and verbal behaviors. Resident #131 confirmed she was responsible for this resident, her care planning and her MDS. Under the guidance to surveyors, F 600 notes the following: In addition, the risk for abuse may increase when a resident exhibits a behavior(s) that may provoke a reaction by staff, residents, or others, such as: Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating; Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; Sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing; Taking, touching, or rummaging through other's property; Wandering into other's rooms/space; and Resistive to care and services. g) Resident #21 According to the quarterly Minimum Data Set (MDS) assessment for Resident #21, with an Assessment Reference Date (ARD) of 07/03/19, Resident #51 has a Brief Interview for Mental Status (BIMS) score of 10. During an interview with Resident #21 on 09/09/19 at 12:15 PM, Resident #21 stated that one resident (Resident #51) bothered her. Resident #21 stated that Resident #51 was getting in other resident rooms when the residents didn't want her in the rooms. Resident #21 stated that she was a resident on the same wing / hall as Resident #51. Resident #21 stated that Resident #51 bothers us when we are trying to eat. She goes through our rooms and messes with our things. She also pours water on the floors in the hallway. You have to keep your door shut to keep her out. On 09/10/19 at 11:52 AM, this surveyor spoke with Director of Nursing (DON) regarding Resident #51. This surveyor interviewed the DON regarding Resident #51's behaviors. The DON stated that Resident #51 has a behavior tracking tool for her behaviors. The DON did note that Resident #51 was not care planned to go in and out of other resident rooms. The DON further noted that she was aware that several residents on A wing had voiced complaints regarding Resident #51's behaviors at meal times and when Resident #51 ambulates on the halls. The DON noted that one of the reasons Resident #51 eats lunch in Special Needs is for her weight loss as well as trying to keep her occupied as to not disturb the residents on A wing. During an interview with Employee #131, MDS nurse on 09/10/19 at 02:20 PM, Employee #131 stated that Resident #51 is not care planned for behavior of wandering and going in and out of other resident rooms. Moreover, Employee #131 reviewed the care plan the facility provided and stated that she did not see where wandering in resident rooms had been careplanned. During an interview on 09/11/19 at 10:15 AM, with Employee #103, Therapeutic Program Director, has Resident #51 on caseload. Resident #51 comes to the Special Needs department for meal training, Monday thru Friday for lunch. On the weekends, Resident #51 eats her meals back on unit. Employee #103 noted that Resident #51 was referred to Special Needs for weight loss, meal intake, and to provide more supervision for resident's behavior. The surveyor spoke with the DON on 09/11/19 at 01:07 PM concerning findings. No further information was provided. h) Resident #11 According to the quarterly Minimum Data Set (MDS) assessment for Resident #11, with an Assessment Reference Date (ARD) of 06/11/19, Resident #51 has a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. During an interview with Resident #11 on 09/09/19 at 12:22 PM, Resident #11 stated that she only had one issue. Resident #11 stated that Resident #51 gets into people's food when they are eating. (NAME of Resident #51) puts her fingers in our food. During the weekdays, they (staff) take her to special needs. But on the weekends, there is not enough staff, so she eats her meals in this (A Wing) dining room. They (staff) need to sit with her so she won't get into people's food. Resident #11 stated that Resident #51 touches other resident's food, paces in the dining room, and yells and rants at the other residents mostly on the weekends. Resident #11 states that she has told staff about her concerns and issues with Resident #51. Resident #11 states that Resident #51 eats in the A wing dining room weekdays for breakfast and dinner and all three meals on the weekends. On 09/10/19 at 11:52 AM, this surveyor spoke with Director of Nursing (DON) regarding Resident #51. This surveyor interviewed the DON regarding Resident #51's behaviors. The DON stated that Resident #51 has a behavior tracking tool for her behaviors. The DON did note that Resident #51 was not care planned to go in and out of other resident rooms. The DON further noted that she was aware that several residents on A wing had voiced complaints regarding Resident #51's behaviors at meal times and when Resident #51 ambulates on the halls. The DON noted that one of the reasons Resident #51 eats lunch in Special Needs is for her weight loss as well as trying to keep her occupied as to not disturb the residents on A wing. During an interview with Employee #131, MDS nurse on 09/10/19 at 02:20 PM, Employee #131 stated that Resident #51 is not care planned for behavior of wandering and going in and out of other resident rooms. Moreover, Employee #131 reviewed the care plan the facility provided and stated that she did not see where wandering in resident rooms had been careplanned. During an interview on 09/11/19 at 10:15 AM, with Employee #103, Therapeutic Program Director, has Resident #51 on caseload. Resident #51 comes to the Special Needs department for meal training, Monday thru Friday for lunch. On the weekends, Resident #51 eats her meals back on unit. Employee #103 noted that Resident #51 was referred to Special Needs for weight loss, meal intake, and to provide more supervision for resident's behavior. The surveyor spoke with the DON on 09/11/19 at 01:07 PM concerning findings. No further information was provided.",2020-09-01
3716,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2019-09-12,607,D,0,1,K00K11,"Based on review of the facility suggestion/complaint forms, policy and procedure, and staff interview, the facility failed to implement written policies and procedures to investigate allegations of neglect for Residents #54, #4, and #64. This was a random opportunity for discovery with the potential to affect a limited number of residents. Resident identifiers: #54, #4, and #64. Facility census: 75. Findings included: a) Review of facility suggestion/complaint forms Review of a facility document entitled, Suggestion/Complaint Form (To be used by all concerned persons) at 1:00 PM on 09/10/19, found a Health Service Assistant (HSA) #171 filed a hand written complaint on behalf of C- North Hall Residents #54, #4 and #64 on 08/23/19. The name of resident's was listed as C North Residents, evening shift. Description of the incident: Residents not being given showers. Attached to the complaint form was a hand written statement from HSA #171: (Typed as written), This is a formal complaint on behalf of several residents that I myself have observed when on the units. I was on C-North today with (Name of Resident # 54) he smelled so bad it was a sour smell. This was not the first time I have smelled that with (Name of Resident #54). He states he has not been in the shower this week they wipe him off and shower him in bed. He also states that when the day shift leaves he gets offered Nothing to drink. Then I observed (Name of Resident #4 ) had crud I'm thinking poop thick under his finger nails and smeared between some of his toes. I know it had to been there a while because it was hard. Also I was told by one/two of day shift CNA's (certified nursing assistants) that (name of resident #64) has not been cleaned properly due to when they change him the cleaning rag would be black. I'm sure there's more but this is what I witnessed myself . I feel I need to speak up for these residents. I will state the ones I mentioned are evening showers that aren't being done. Attached to the complaint form was also a hand written statement from Health Services Worker (HSW) #145, dated 8/23/19. There has been multiple occasions that I have worked with (name of Resident #54) and he has made the statement that he did not get a shower, yet his face had been shaved. When I ask him where did they shave you at he has stated in my bed. (Name of Resident #54) has also had an odor coming from him. When wiping and doing care on (Name of Resident #64 a brown residue is left on the wash rag Also attached to the complaint form was a handwritten statement, dated 08/23/19, from HSW #134. There have been multiple times that myself and other HSW have went in to do care on (Resident name) and have noticed a very strong odor coming from him. Resident also stated to HSW that they only shave him and wipe him off while laying in bed. Also, while doing care on (Name of Resident) I noticed as you wipe him a brown residue will come off of him. The suggestion/complaint form required the following to be completed: Steps taken to investigate: Check the shower schedule, et (typed as written) monitor the bathing of the patients. Summary of findings/conclusion: Rsdt's (Residents) were bathed as scheduled. Witnessed rsdt's shower via shower gurney. Statement Complaint valid/not valid: Not valid. Corrective action? (if any) Monitor rsdt's et their bathing schedule et ensure completion. The form was signed only by the Assistant Director Of Nursing (ADON). The form also required the signature of the administrator. The form was not signed. On 09/10/19 at 03:58 PM, a facility social work supervisor (SWS) #56 said she was aware of the allegations but she did not investigate them. She said the allegations were not reported to the proper state agencies because she didn't think the allegations were true. An interview with the ADON on 09/10/19 at 4:09 PM, revealed the allegations were not reported to State authorities. The ADON said she had placed a sticky note on the complaint form noting each resident was showered. The ADON pointed to the note which indicated each resident was showered on 08/23/19; #54 received a shower at 3:30 PM, #4 received at shower at 3:50 PM, and #64 received a shower at 4:10 PM. When asked if she had any other information to provide regarding the situation, she said, no. The ADON retrieved the shower schedule for the 3 residents in question. All 3 residents are to receive showers on the afternoon shift. Review of the schedule with the ADON revealed the following information from 08/01/19 through 08/23/19: Resident #54 receives showers on Monday, Wednesday, and Friday. Resident #54 was not showered on the following Mondays in August, 2019 8/5/19, 8/19/19. Resident #54 was not showered on the following Fridays in August, 2019: 08/02/19, 08/09/19, 08/16/19. Resident #4 receives showers on Saturday, Tuesday and Thursday. Resident #4 missed the following showers on Saturdays: 08/10/19, 08/17/19. Resident #64 is showered on Monday, Wednesday, and Friday. Resident #64 did not receive a shower on 08/02/19, 08/05/19, 08/09/19, and 08/16/19. The ADON agreed the residents were not bathed as scheduled prior to the allegation. The ADON said she did not obtain any statements from other staff. She obtained no statements from the afternoon staff responsible for bathing the 3 residents. She did not have any information to determine why these 3 residents were not provided showers as scheduled. There was also no investigation into the allegation regarding Resident #54, Doesn't get anything to drink. An interview with HSA #171 on 09/11/19 at 10:13 AM, found she works on the special needs unit. HSA verified she made a complaint because, These Residents need to be taken care of. She said she witnessed what she believed to be human feces on Resident #4. She also witnessed a odor coming from Resident #54. She said another worker told her about Resident #64. An interview with the administrator on 09/11/19 at 10:56 AM revealed the administrator was unaware of the suggestion/complaint form completed on 08/23/19. Review of the facility's policy, entitled Abuse and Neglect Reporting/investigation, defines neglect as, The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Under the heading investigation: The hospital will investigate different types of incidents and identify the staff member responsible for initial reporting, investigation of alleged violations and reporting of results to the proper authorities. 4. The investigation will focus on determining if abuse, neglect, exploitation, involuntary seclusion, misappropriation of resident property and/or mistreatment has occurred, the extent, and cause.",2020-09-01
3717,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2019-09-12,609,D,0,1,K00K11,"Based on review of the facility suggestion/complaint forms, facility policy and procedure, and staff interview, the facility failed to ensure allegations of neglect were reported in accordance with State law to the State Survey Agency, Ombudsman, and adult protective services. In addition, the administrator was unaware of the allegations. This was a random opportunity for discovery with the potential to affect a limited number of residents. Resident identifiers: #54, #4, and #64. Facility census: 75. Findings included: a) Review of facility suggestion/complaint forms Review of a facility document entitled, Suggestion/Complaint Form (To be used by all concerned persons) at 1:00 PM on 09/10/19, found a Health Service Assistant (HSA) #171 filed a hand written complaint on behalf of C- North Hall Residents #54, #4 and #64 on 08/23/19. The name of resident's was listed as C North Residents, evening shift. Description of the incident: Residents not being given showers. Attached to the complaint form was a hand written statement from HSA #171: (Typed as written), This is a formal complaint on behalf of several residents that I myself have observed when on the units. I was on C-North today with (Name of Resident # 54) he smelled so bad it was a sour smell. This was not the first time I have smelled that with (Name of Resident #54). He states he has not been in the shower this week they wipe him off and shower him in bed. He also states that when the day shift leaves he gets offered Nothing to drink. Then I observed (Name of Resident #4 ) had crud I'm thinking poop thick under his finger nails and smeared between some of his toes. I know it had to been there a while because it was hard. Also I was told by one/two of day shift CNA's (certified nursing assistants) that (name of resident #64) has not been cleaned properly due to when they change him the cleaning rag would be black. I'm sure there's more but this is what I witnessed myself . I feel I need to speak up for these residents. I will state the ones I mentioned are evening showers that aren't being done. Attached to the complaint form was also a hand written statement from Health Services Worker (HSW) #145, dated 8/23/19. There has been multiple occasions that I have worked with (name of Resident #54) and he has made the statement that he did not get a shower, yet his face had been shaved. When I ask him where did they shave you at he has stated in my bed. (Name of Resident #54) has also had an odor coming from him. When wiping and doing care on (Name of Resident #64 a brown residue is left on the wash rag Also attached to the complaint form was a handwritten statement, dated 08/23/19, from HSW #134. There have been multiple times that myself and other HSW have went in to do care on (Resident name) and have noticed a very strong odor coming from him. Resident also stated to HSW that they only shave him and wipe him off while laying in bed. Also, while doing care on (Name of Resident) I noticed as you wipe him a brown residue will come off of him. The suggestion/complaint form required the following to be completed: Steps taken to investigate: Check the shower schedule, et (typed as written) monitor the bathing of the patients. Summary of findings/conclusion: Rsdt's (Residents) were bathed as scheduled. Witnessed rsdt's shower via shower gurney. Statement Complaint valid/not valid: Not valid. Corrective action? (if any) Monitor rsdt's et their bathing schedule et ensure completion. The form was signed only by the Assistant Director Of Nursing (ADON). The form also required the signature of the administrator. The form was not signed. On 09/10/19 at 03:58 PM, a facility social work supervisor (SWS) #56 said she was aware of the allegations but she did not investigate them. She said the allegations were not reported to the proper state agencies because she didn't think the allegations were true. An interview with the ADON on 09/10/19 at 4:09 PM, revealed the allegations were not reported to State authorities. The ADON said she had placed a sticky note on the complaint form noting each resident was showered. The ADON pointed to the note which indicated each resident was showered on 08/23/19; #54 received a shower at 3:30 PM, #4 received at shower at 3:50 PM, and #64 received a shower at 4:10 PM. When asked if she had any other information to provide regarding the situation, she said, no. The ADON retrieved the shower schedule for the 3 residents in question. All 3 residents are to receive showers on the afternoon shift. Review of the schedule with the ADON revealed the following information from 08/01/19 through 08/23/19: Resident #54 receives showers on Monday, Wednesday, and Friday. Resident #54 was not showered on the following Mondays in August, 2019 8/5/19, 8/19/19. Resident #54 was not showered on the following Fridays in August, 2019: 08/02/19, 08/09/19, 08/16/19. Resident #4 receives showers on Saturday, Tuesday and Thursday. Resident #4 missed the following showers on Saturdays: 08/10/19, 08/17/19. Resident #64 is showered on Monday, Wednesday, and Friday. Resident #64 did not receive a shower on 08/02/19, 08/05/19, 08/09/19, and 08/16/19. b) Interviews with staff The ADON agreed the residents were not bathed as scheduled prior to the allegation. The ADON said she did not obtain any statements from other staff. She obtained no statements from the afternoon staff responsible for bathing the 3 residents. She did not have any information to determine why these 3 residents were not provided showers as scheduled. There was also no investigation into the allegation regarding Resident #54, Doesn't get anything to drink. An interview with HSA #171 on 09/11/19 at 10:13 AM, found she works on the special needs unit. HSA verified she made a complaint because, These Residents need to be taken care of. She said she witnessed what she believed to be human feces on Resident #4. She also witnessed a odor coming from Resident #54. She said another worker told her about Resident #64. An interview with the administrator on 09/11/19 at 10:56 AM revealed the administrator was unaware of the suggestion/complaint form completed on 08/23/19. The administrator was unaware of any investigations that may or may not have occurred. The administrator verified she should have been made aware of the concern form. c) Facility Policy and procedure for Abuse and Neglect Reporting/Investigation Review of the facility's policy, entitled Abuse and Neglect Reporting/reporting/response: A covered individual (mandatory reported) will immediately report to Adult Protective Services, State Agency, (OHFLAC), the administrator and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's. The mandatory reported may contact the Resident Advocate/Grievance Official for assistance if needed. The Charge Nurse will assist with reporting of allegations on nights, weekends and holidays Allegations that DO NOT involve abuse or result in serious bodily injury must be reported to appropriate State agencies no later than 24 hours after allegation is made. Additionally, as a result of the investigation the facility will take all necessary actions which may include, but are not limited to, the following: Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; Defining how care provision will be changed and /or improved to protect residents receiving services; Training of staff on changes made and demonstration of staff competency after training is implemented; Identification of staff responsible for implementation of corrective actions; The expected date for implementation; and Identification of staff responsible for monitoring the implementation of the plan.",2020-09-01
3718,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2019-09-12,656,E,0,1,K00K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and resident interview, the facility failed to ensure each resident will have a person-centered comprehensive care plan developed and implemented to meet his / her other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs for Residents #51, #60, #58, and #63. For Resident #51, the facility failed to develop a care plan to address the resident's wandering as it relates to potential accidents, implement the care plan for activities, and develop a care plan for behaviors. For Resident #60, the facility failed to implement a care plan for a resident with dementia. For Resident #58, the facility failed to implement a care plan for a resident with fall precautions. For Resident #63, the facility failed to develop a care plan to address a resident's dental issues. This was true for four (4) of eighteen (18) residents reviewed. Resident identifiers: #51, #58, #58, and #63. Facility census 75. Findings included: a -1 ) Resident #51 (Accidents) During the initial tour as well as meal observation on 09/09/19 at 12:53 PM, Resident #51 was wandering around the A wing dining room. Below are the observations the day of entrance of Resident #51's behaviors: --09/09/19 12:53 PM R 51 wandering. --09/09/19 12:56 PM R 51 trying to touch items on other resident's trays. Resident #51 stands over Resident #11 as R #11 is trying to eat her lunch. --09/09/19 12:58 PM Employee #22, LPN, redirected R #51 from R #11's food --09/09/19 01:07 R #51 going in and out of rooms on A North wing. R #51 removed water pitcher from Room A-5. R #51 placed the water pitcher on a blue recliner that was covered in plastic protective cover that was located in the hallway. R #51 rummaged in all drawers in room A-2. R #51 then lies in bed in A-2. R #51 goes in and out of that room. There are no staff that can be seen on this A North unit at this time. --09/09/19 01:08 PM R #51 goes into room A-1. Employee #115, housekeeper, was cleaning in Room A-1. Employee #115 told Resident #51 that the room was not her room and that the resident could not be in that room. Employee #115 remained cleaning Room A-1 while Resident #51 was still in Room A-1. --09/09/19 01:09 PM R #51 went into Room A-3. There were no staff on hall that were visible. R #51 was rummaging in Room A-3. --09/09/19 01:10 PM R #51 went back into Room A-1. Employee #22, LPN, was present A North hall. Employee #22 walked by R #51 while she was in Room A-1. Employee #22 did not stop R #51 from going into room that was not hers nor did Employee #22 try to redirect R #51 from rummaging and touching items in Room A-1. --09/09/19 01:11 PM R #51 went back into Room A-2. R #51 was rummaging on all 3 beds in that are in Room A-3. Employee #22 was still present on A North wing. Employee #22 did not attempt to stop nor redirect Resident #51. --09/09/19 01:12 PM Resident #51 entered Room A-3. R #51 was rummaging on bed. This is not R #51's room. Employee #22, LPN, walked off of the hall of A North wing and exited through the doors at the nurses' station. Employee #22 did not intervene nor redirect R #51 from being in Room A-3. During this time, R #51, was rummaging on another bed. R #51 was touching and adjusting 2 of the 3 beds in this room. --09/09/19 01:13 PM Resident #51 went back into Room A-3. R #51 walked around the room and touched nightstands, bed, and chairs. --09/09/19 01:14 PM Resident #51 went back into Room A-3. Employee #22 walked in and out of this room while R #51 was wandering in this room. This is not Resident #51's room. Employee #22 did not redirect or try to have resident exit room. R #51 exited the room at 1:15 PM. --09/09/19 01:19 PM R #51 entered Room A-1. R #51 was rummaging through this room. --09/09/19 01:20 PM Resident #51 entered Room A-2 and walked around the room touching various items in this room, including items that are not hers. --09/09/19 01:21 PM Resident entered Room A-2. This is R #51's room; however, R #51 was going through other resident items that on the other beds in this room. --09/09/19 01:24 PM Resident #51 was going in and out of rooms on A east. Employee #22, LPN did see Resident #51, but did not redirect the resident. --09/09/19 04:06 PM Resident #51 was cursing another resident (Resident #1). This occurred in the hallway before the entrance door to A East. Resident #51 was telling Resident #1 that he is going to hell. --09/09/19 04:09 PM Resident #51 entered Room A-11. --09/09/19 04:15 PM Resident #51 was touching Resident #18's drink. Resident #18 stated you go on. leave that alone. Review of Residents #51's care plan found a focus/problem: --Needs assistance with ADL's, is at risk for decline due to cognitive loss, alteration in thought process r/t [DIAGNOSES REDACTED], history of incontinence. The goal associated with this problem: --Will be able to continue self care a much as possible and accept staff assistance PRN with ADL's over the next review. Interventions included: --May observe 1 : 1 of line of sight if resident appears agitated / and or unsteady prn. --History of using razors to shave her face causing her face and neck to have open areas bleeding. Refer to MD. Shave [NAME] PRN. Maintain razor safety. A record review of Resident #51 noted that this resident had two (2) incident / accident reports since 07/31/19. On 07/31/19 at 01:45 PM, Resident #51 was discovered in the employee bathroom. The incident / accident report description stated, Resident went into employee bathroom and attempted to urinate in tub. Resident pulled her pants down and fell backward into tub. Resident was not hurt. On 09/05/19 at 09:05 am, Resident #51 was lying in her bed, at some point woke up and urinated / defecated on her bed and floor. At that time, resident attempted to stand and slipped ion her urine on the floor causing her to fall at bedside. A record review of Resident #51's chart revealed an Elopement Risk Evaluation Tool dated 08/02/19. Resident #51 had a total score of 10. On the Elopement Risk Evaluation Tool, there is a scale to define each score. A score of 9+ is defined as high risk to wander requires secure care device care plan and monitor as directed. Resident #51 had behavior / intervention monthly flow record in her chart. The behaviors listed on these tracking forms for staff to monitor for were agitated / pacing and panic / anxiety. A record review of the facility's behavior / intervention monthly flow record for the months from (MONTH) 2019 to (MONTH) 2019 listed a behavior of agitated / pacing. However, on each month's sheet, the staff documented only zero's (O) on the tracking tools. On 09/11/19 at 12:39 PM, during an interview with Assistant Director of Nursing (ADON), this surveyor asked the ADON what a zero (0) on the behavior tracking form meant. The ADON responded that a zero (0) meant that the staff stated that the behavior did not occur. A record review of Resident #51 noted the following nurses notes (copied as written in resident's chart): --6/2/19 at 15:46: Resident cont. (continues) to be restless and agitated this shift. PRN (as needed) [MEDICATION NAME] given per order with minimal effect. Resident has been going into resident #9180 room causing that resident to become agitated. Multiple attempts at redirection, but behavior cont. throughout this shift. Placed on cb for physician review charge nurse notified of prn [MEDICATION NAME] and resident change in behavior, notified POA (Power of Attorney)/family [NAME] of residents change in behavior. Family noted to increase in agitation, as they attempted an outing with resident when she became extremely agitated and attempted to bite daughter. Pre restraint form completed. --6/3/19 at 20:00: Resident receives prn [MEDICATION NAME] having agitation, yelling very loud in dayroom as staff attempts to redirect her from going in other resident's rooms, she refuses snacks and drinks as staff attempts to change her mood with snack or drink, resident spills pop on her bed leaving the near full can on her blankets. --6/5/19 at 00:02: Resident receives her prn [MEDICATION NAME] for agitation as she has been offered snacks and drinks to shift her mood, while she was in the bathroom, she removed her depends, torn up depends but into the three bathroom sinks and turned the water on, staff has returned her to her bed several times since 10:30pm and hopefully she will be able to get some rest having received her prn. --6/5/19 at 01:32 Reside up out of bed, ambulates to bathroom on A North, spends a little time in the bathroom, water could be heard running, staff goes to the bathroom to find all three sinks with paper towels and toilet paper in the sink with the water running strong and water overflowing into the floor, one toilet plugged up also, night shift staff clean up bathroom, resident currently in room lying on bed as if asleep. --6/6/19 at 12:25 Night shift charge nurse reported concerns about [NAME] and her recent worsening of behaviors, her increase incidents of behaviors, such as wandering, taking items from others, screaming at staff, making false accusations, plugging up the toilet and sink, tearing dressing off her arm. (Psychiatric Physician name) ask us to consult with (Attending Physician name), and to do medical work up such as labs and ua. Notified (attending physician) of the above concerns and he plans to see (resident) on his visit tomorrow. --6/8/19 at 20:00 Resident receives prn [MEDICATION NAME] for aggression, as we were unable to change her mood by offering snacks, drinks or restroom needs, she had returned to the bathroom and was found with wet towels in the sink and the water running, she has been pacing and can be heard repeating herself, she speaks hateful when staff attempts to move her away from the bathroom sink or away from another resident as she stands in their personal space. --6/9/19 at 20:20 Resident receives prn [MEDICATION NAME] for aggression, she can be heard talking hateful as staff attempts to redirect her away from other residents, she is not concerned with a snack or drink this writer offers a drink and she will say 'I don't want it', she had been following staff into other resident's room as staff is assisting other resident's to bed, she stands in the doorway talking to herself, when staff asks her to leave or the resident of the room asks her to leave she becomes hateful in her response by the time staff walks her out of the room she is fitful and returns to the same place as if she intends to do what she wants. --6/11/19 at 06:31 Resident given PRN [MEDICATION NAME] at HS for agitation. Rsdt walking very quickly down the halls, clenching fists and yelling, 'I'm leaving, I'm leaving.' Slept through night and woke up at appx 5 am and picked off scabbed areas on lower R arm. Areas cleaned and dry dressings applied and also covered with long sleeve. --6/11/19 at 23:00 Resident received prn [MEDICATION NAME] for aggression, being unable to calm self, uncooperative to accept sandwich or drink, she has been yelling very loud paces hallways is returned to unit per staff and continues to be loud. --6/17/19 at 20:00 Resident receives prn [MEDICATION NAME] for anxiety as drinks and snacks does not seem to help improve her mood, she continues to pace, repeat herself and speaks of leaving. --6/21/19 at 06:17 Resident agitated this evening, yelling at staff, stating that she wants to leave, walking very quickly up and down the halls. Unable to redirect with snack. PRN [MEDICATION NAME] given at 8pm. --6/22/19 at 06:04 Resident very agitated, picking at scabs on her arm and saying she wants to 'get out of here and never coming back.' Attempts to redirect her with a snack and juice are unsuccessful. PRN [MEDICATION NAME] given per MD order. --7/4/19 at 09:08 Resident ambulating in hallway, agitated. yelling at staff. Uncooperative with care. Multiple attempts at Redirection unsuccessful. Prn med given with success. --7/5/19 at 20:46 HSW (health service worker) stated that resident has been turning on all the sinks, yelling at residents in the hallway, saying, 'it hurts, I've got to get out of here!' Unable to redirect her. Gave her a PRN [MEDICATION NAME] for her agitation . --7/9/19 at 10:00 Resident was getting into trash and other resident's belongings. Pacing back and forth. Redirection unsuccessful. [MEDICATION NAME] 1mg po given per order. --7/11/19 at 20:00 Received prn [MEDICATION NAME] for anxiety, after receiving a drink, snack, and encouraged to sit down, but continued pacing and yelling. --7/12/19 at 10:44 Resident pacing and yelling. Drinks and food offered with no success. PRN [MEDICATION NAME] given as ordered. --7/15/19 at 20:15 Resident had got into the big trash can on the unit and got a diaper out of it and rubbed her face with it getting BM on her nose and cheek. Hsw cleaned it off and redirected resident to stay out of the trash can. --7/15/19 at 20:30 Resident receives prn [MEDICATION NAME] for agitation after receiving snacks and a drink and being unable to improve her mood, she has been unable to verbally redirect as she paces the unit, goes in and out of other resident's rooms, she picked up a blanket belonging to another resident becomes more loud and argumentative when verbally redirected to return items, other residents become upset which has caused loud outburst on unit, she removes several pairs of depends off the cart, takes gloves out of the boxes on the wall, tears on the occupied sign that is on the staff's restroom door. --7/16/19 at 10:22 Resident was becoming more agitated, getting into other resident's belongings. Got resident # 9120 remote. Very uncooperative. [MEDICATION NAME] 1mg po given. --7/17/19 at 01:45 Resident had been asleep earlier but is now awake, assisted to bathroom, assisted back to bed but up gotten up self up out of bed and walking unit, going into other resident's rooms, becomes argumentative when verbally redirected by staff, encouraged to sit in chair on hall and would only sit for a brief period of time, received drink and snack but did not improve her mood, received [MEDICATION NAME] PRN PO for agitation. --7/17/19 at 20:15 Receives PRN PO (by mouth) [MEDICATION NAME] for agitation after resident's mood is unchanged by being offered snacks, drink, urged to sit down, or lay down, she has been pacing hallway and going into other resident's rooms. Some residents fuss at her to leave the room she then becomes loud, has a frown and stomps as she walks and talks as if angry, 'I'm leaving here, I'm not coming back' she repeats this phrase and as she continues this behavior. --7/19/19 06:27 Resident was given PRN [MEDICATION NAME] at HS (at bedtime) d/t (due to) her behaviors. She was agitated, pacing the floor, yelling at others. Unable to distract resident by offering a snack or a drink. Took medications without incident. --7/21/19 at 20:00 Med prn for anxiety et pain. Pacing et (and) worried expression. --7/24/19 at 06:42 Resident was repeating, 'it hurts, it hurts. She was walking very quickly into other resident rooms, getting into the trash can in the hallway, turning on the sinks in the bathroom. Unable to distract rsdt with juice or snacks and wouldn't sit in the recliner. Administered PRN [MEDICATION NAME] for her agitation . --7/25/19 at 21:19 Resident was screaming at HSWs that were trying to calm her down, asking her to sit in the chair. HSW reported that for the past few hours, rsdt has been going into the bathroom and turning on the sinks; digging in the trash, going into others rooms and messing with others belongings and picking at her arms. At 8pm, this nurse administered a PRN [MEDICATION NAME] to her, per MD order. --7/26/19 at 00:53 Resident awoke at approx 2400. She is very irritable, screaming at the HSW and running down the hall. She continuously entered bedrooms that weren't' her own, sitting on top of resident who were sleeping. Tried to redirect with a drink and a snack, but resident became louder and angrier. Administered a PRN [MEDICATION NAME] per MD order at this time --7/29/19 at 00:02 Resident pulling dirty briefs out of the trash. She is very upset, yelling at HSW, 'I've got to go, get out, get out!' Unable to redirect to recliner. Offered snack, but declined. Administered PRN [MEDICATION NAME] per MD order at this time. --7/30/19 at 16:30 This resident was getting anxious, pacing back and forth and going into other residents rooms. Redirection unsuccessful, would just get more agitated. [MEDICATION NAME] 1mg po given per order. --7/31/19 at 08:09 Resident ambulating up and down hallway. In and out of other resident rooms. screaming 'it hurts' Redirection unsuccessful. Prn [MEDICATION NAME] and anxiety med given with success. --8/3/19 at 06:51 Resident ambulating on the unit, yelling out, 'It hurts, it hurts.' --8/6/19 at 22:06 Resident has displayed increased agitation / anxiety during this HS med pass. She is going into the bathroom, turning on the faucets, then will start screaming profanities very loudly when attempting to redirect her. She shouts, 'I'm leaving. I'm going home, I'm not coming back, F--k you. Attempted to redirect resident with different snacks, juices, but with no success. Took HS medication without incident. --8/7/19 at 15:15 This resident was standing out in the hall and resident #9152 rolled up to her and hit her in the stomach. Resident yelled out and resident #9152 rolled on down the hall in his w/c (wheelchair). --8/21/19 at 06:20 Resident seems agitated with staff and with other residents. Attempted to redirect her. Offered snack/drinks. Walked briskly through the halls and was saying, 'I'm leaving, I'm leaving. It hurts, hurts, hurts, blood, blood.' PRN [MEDICATION NAME] per MD order. --8/23/19 at 23:20 Resident was getting into the towels and wash clothes and had them in the floor in the bathroom. Going into other residents rooms while they are sleeping. [MEDICATION NAME] 1mg po given. --8/28/19 at 02:06 Resident with increased agitation, attempting to get into bed with other residents, yelling at Staff, attempts were made to help Resident get comfortable, PRN [MEDICATION NAME] administered, will continue to monitor. --8/30/19 at 04:34 Resident showing increased agitation during HS med pass. She was going into other residents rooms, climbing into their beds, screaming out. Unable to redirect to a recliner or with a snack. PRN [MEDICATION NAME] administered per MD order. --08/31/19 at 06:35 Resident was very agitated, pacing the halls, yelling out at other residents. Offered a snack/drink; Unable to redirect at this time. PRN [MEDICATION NAME] given at this time, per MD order for agitation. --09/05/19 at 07:15 Resident already agitated this morning, yelling and pacing. PRN [MEDICATION NAME] and PRN [MEDICATION NAME] administered. Will continue to monitor. --09/05/19 at 11:55 Administered second dose of PRN [MEDICATION NAME] and PRN [MEDICATION NAME] due to the resident expressing being in pain as well as starting to pace and become agitated when being redirected. Will continue to monitor. --09/05/19 at 14:32 Reported by ADON to this nurse that resident was found lying in another resident's bed on C wing. No incident occurred. Resident redirected out of room / bed. Will continue to monitor. During an interview with Employee #131, Minimum Data Set (MDS) nurse on 09/10/19 at 02:20 PM regarding Resident #51's care plan, Employee #131 and this surveyor reviewed Resident #51's care plan provided by the facility. This surveyor asked Employee #131 where the care plan would state that Resident #51 went into other resident rooms as well as other areas of the facility. Employee #131 stated that she was not aware that Resident #51 entered other resident rooms and went through items of other residents. This surveyor noted that there were nurses notes regarding the resident's behavior. Surveyor asked Employee #131 why the access to razors still remained on Resident #51's care plan. Employee # responded that Resident #51 was still able to have access to razors. There are residents on the unit that can shave themselves and there are razors on the unit for those residents to use. (NAME OF RESIDENT #51) is care planned for a history of razors since she is able to get razors and shave face. Once Resident #51 was no longer able to shave herself, the staff had to confiscate razors. The nurse aids shave her now. We do have residents on that wing who use razors. Employee #131 was not able to find where Resident #51 was care planned for wandering into other resident rooms as well as other rooms on the unit and any interventions to address that behavior. Employee #131 did state that with Resident #51 going into areas on the unit as well as other resident rooms, that would pose an potential for an accident. On 09/11/19 at 01:07 PM, this surveyor spoke with Director of Nursing (DON) concerning findings. No additional information was provided. a-2) Resident #2 (Activities) During the initial tour as well as meal observation on 09/09/19 at 12:53 PM, Resident #51 was wandering around the A wing dining room. Resident #51 tried to touch the food items on Resident #11's lunch tray. Resident #51 would pace and wander the A wing dining room., then return to a seat near Resident #11. When Resident #51 would sit near Resident #11, Resident #51 would attempt to touch Resident #11's food items and grab at the items on Resident #11's tray. Below are the observations the day of entrance of Resident #51's behaviors: --09/09/19 12:53 PM R 51 wandering. --09/09/19 12:56 PM R 51 trying to touch items on other resident's trays. Resident #51 stands over Resident #11 as R #11 is trying to eat her lunch. --09/09/19 12:58 PM Employee #22, LPN, redirected R #51 from R #11's food --09/09/19 01:07 R #51 going in and out of rooms on A North wing. R #51 removed water pitcher from Room A-5. R #51 placed the water pitcher on a blue recliner that was covered in plastic protective cover that was located in the hallway. R #51 rummaged in all drawers in room A-2. R #51 then lies in bed in A-2. R #51 goes in and out of that room. There are no staff that can be seen on this A North unit at this time. --09/09/19 01:08 PM R #51 goes into room A-1. Employee #115, housekeeper, was cleaning in Room A-1. Employee #115 told Resident #51 that the room was not her room and that the resident could not be in that room. Employee #115 remained cleaning Room A-1 while Resident #51 was still in Room A-1. --09/09/19 01:09 PM R #51 went into Room A-3. There were no staff on hall that were visible. R #51 was rummaging in Room A-3. --09/09/19 01:10 PM R #51 went back into Room A-1. Employee #22, LPN, was present A North hall. Employee #22 walked by R #51 while she was in Room A-1. Employee #22 did not stop R #51 from going into room that was not hers nor did Employee #22 try to redirect R #51 from rummaging and touching items in Room A-1. --09/09/19 01:11 PM R #51 went back into Room A-2. R #51 was rummaging on all 3 beds in that are in Room A-3. Employee #22 was still present on A North wing. Employee #22 did not attempt to stop nor redirect Resident #51. --09/09/19 01:12 PM Resident #51 entered Room A-3. R #51 was rummaging on bed. This is not R #51's room. Employee #22, LPN, walked off of the hall of A North wing and exited through the doors at the nurses' station. Employee #22 did not intervene nor redirect R #51 from being in Room A-3. During this time, R #51, was rummaging on another bed. R #51 was touching and adjusting 2 of the 3 beds in this room. --09/09/19 01:13 PM Resident #51 went back into Room A-3. R #51 walked around the room and touched nightstands, bed, and chairs. --09/09/19 01:14 PM Resident #51 went back into Room A-3. Employee #22 walked in and out of this room while R #51 was wandering in this room. This is not Resident #51's room. Employee #22 did not redirect or try to have resident exit room. R #51 exited the room at 1:15 PM. --09/09/19 01:19 PM R #51 entered Room A-1. R #51 was rummaging through this room. --09/09/19 01:20 PM Resident #51 entered Room A-2 and walked around the room touching various items in this room, including items that are not hers. --09/09/19 01:21 PM Resident entered Room A-2. This is R #51's room; however, R #51 was going through other resident items that on the other beds in this room. --09/09/19 01:24 PM Resident #51 was going in and out of rooms on A east. Employee #22, LPN did see Resident #51, but did not redirect the resident. --09/09/19 04:06 PM Resident #51 was cursing another resident (Resident #1). This occurred in the hallway before the entrance door to A East. Resident #51 was telling Resident #1 that he is going to hell. --09/09/19 04:09 PM Resident #51 entered Room A-11. --09/09/19 04:15 PM Resident #51 was touching Resident #18's drink. Resident #18 stated you go on. leave that alone. Review of Residents #51's care plan found a focus/problem: 001 - At risk for [MEDICAL CONDITIONS], GERD, weight loss from pacing throughout the facility, history of zinc/[MEDICATION NAME] and vitamin B 12 deficiency. The goal associated with this problem: Will not have complications r/t [MEDICAL CONDITION], stomach discomfort, mineral deficiencies, and weight loss, over the next review period. Interventions included: -- History of taking food from other residents, monitor to prevent occurrences. -- Activities to provide activities at lunch time for [NAME] when is finished lunch. During an interview with Employee #131, Minimum Data Set (MDS) nurse, on 09/10/19 at 02:20 PM regarding Resident #51's care plan, Employee #131 and this surveyor reviewed Resident #51's care plan provided by the facility. This surveyor asked Employee #131 why Resident #51 was referred to Special Needs. Employee #131 stated that there was an order for [REDACTED].#51's trying to take their food while they were eating. On 09/11/19 at 01:07 PM, this surveyor spoke with Director of Nursing (DON) concerning findings. No additional information was provided. a- c) Resident #51 (behavioral / mood) A record review of Resident #51's most recent Minimum Data Set (MDS), with an assessment reference date (ARD) of 08/02/19, coded the resident as having physical behavior (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) as having occurred 4 to 6 times in the last 7 days but less than daily. Verbal behavior directed towards other, threatening screaming, and cursing as having occurred daily in the last 7 days. During the initial tour as well as meal observation on 09/09/19 at 12:53 PM, Resident #51 was wandering around the A wing dining room. Resident #51 tried to touch the food items on Resident #11's lunch tray. Resident #51 would pace and wander the A wing dining room., then return to a seat near Resident #11. When Resident #51 would sit near Resident #, Resident #51 would attempt to touch Resident #11's food items and grab at the items on Resident #11's tray. Below are the observations the day of entrance of Resident #51's behaviors: --09/09/19 12:53 PM R 51 wandering on A wing. --09/09/19 12:56 PM R 51 trying to touch items on other resident's trays. Resident #51 stands over Resident #11 as R #11 is trying to eat her lunch. --09/09/19 12:58 PM Employee #22, LPN, redirected R #51 from R #11's food --09/09/19 01:07 R #51 going in and out of rooms on A North wing. R #51 removed water pitcher from Room A-5. R #51 placed the water pitcher on a blue recliner that was covered in plastic protective cover that was located in the hallway. R #51 rummaged in all drawers in room A-2. R #51 then lies in bed in A-2. R #51 goes in and out of that room. There are no staff that can be seen on this A North unit at this time. --09/09/19 01:08 PM R #51 goes into room A-1. Employee #115, housekeeper, was cleaning in Room A-1. Employee #115 told Resident #51 that the room was not her room and that the resident could not be in that room. Employee #115 remained cleaning Room A-1 while Resident #51 was still in Room A-1. --09/09/19 01:09 PM R #51 went into Room A-3. There were no staff on hall that were visible. R #51 was rummaging in Room A-3. --09/09/19 01:10 PM R #51 went back into Room A-1. Employee #22, LPN, was present A North hall. Employee #22 walked by R #51 while she was in Room A-1. Employee #22 did not stop R #51 from going into room that was not hers nor did Employee #22 try to redirect R #51 from rummaging and touching items in Room A-1. --09/09/19 01:11 PM R #51 went back into Room A-2. R #51 was rummaging on all 3 beds in that are in Room A-3. Employee #22 was still present on A North wing. Employee #22 did not attempt to stop nor redirect Resident #51. --09/09/19 01:12 PM Resident #51 entered Room A-3. R #51 was rummaging on bed. This is not R #51's room. Employee #22, LPN, walked off of the hall of A North wing and exited through the doors at the nurses' station. Employee #22 did not intervene nor redirect R #51 from being in Room A-3. During this time, R #51, was rummaging on another bed. R #51 was touching and adjusting 2 of the 3 beds in this room. --09/09/19 01:13 PM Resident #51 went back into Room A-3. R #51 walked around the room and touched nightstands, bed, and chairs. --09/09/19 01:14 PM Resident #51 went back into Room A-3. Employee #22 walked in and out of this room while R #51 was wandering in this room. This is not Resident #51's room. Employee #22 did not redirect or try to have resident exit room. R #51 exited the room at 1:15 PM. --09/09/19 01:19 PM R #51 entered Room A-1. R #51 was rummaging through this room. --09/09/19 01:20 PM Resident #51 entered Room A-2 and walked around the room touching various items in this room, including items that are not hers. --09/09/19 01:21 PM Resident entered Room A-2. This is R #51's room; however, R #51 was going through other resident items that on the other beds in this room. --09/09/19 01:24 PM Resident #51 was going in and out of rooms on A east. Employee #22, LPN did see Resident #51, but did not redirect the resident. --09/09/19 04:06 PM Resident #51 was cursing another resident (Resident #1). This occurred in the hallway before the entrance door to A East. Resident #51 was telling Resident #1 that he is going to hell. --09/09/19 04:09 PM Resident #51 entered Room A-11. --09/09/19 04:15 PM Resident #51 was touching Resident #18's drink. Resident #18 stated you go on. leave that alone. Review of Residents #51's care plan found a focus/problem: At risk for [MEDICAL CONDITIONS], GERD, weight loss from pacing throughout the facility, history of zinc/[MEDICATION NAME] and vitamin B 12 deficiency. The goal associated with this problem: Will not have complications r/t [MEDICAL CONDITION], stomach discomfort, mineral deficiencies, and weight loss, over the next review period. Interventions included: -- [NAME] paces and wanders throughout the facility throughout the day, [MEDICAL CONDITION] with her ambulation. History of thinking she is fat. -- History of taking food from other residents, monitor to prevent occurrences. Needs assistance with ADL's, is at risk for decline due to cognitive loss, alteration in thought process r/t [DIAGNOSES REDACTED], history of incontinence. The goal associated with this problem: Will be able to continue self care a much as possi (TRUNCATED)",2020-09-01
3719,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2019-09-12,697,D,0,1,K00K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview the facility failed to evaluate the effectiveness of an as needed (PRN) pain medication that was administered to Resident #1. This was true for one (1) of (2) Residents reviewed in the care area of pain. Resident identifier: #1. Facility census: 75. Findings included: a) Resident #1 During an interview on 09/09/19 at 11:20 am, Resident #1 complained of pain and hurting in his lower back and stomach area. Review of Active Orders revealed the Resident had an order for [REDACTED]. Review of the facility's Medication Administration policy stated for PRN medications the nurse must assess the Resident prior to the first dose of any PRN or STAT medication and then reassess the Resident within 60 minutes and complete the PRN effectiveness report. Record review of the Medication Therapy Report indicated from 08/01/19 - 09/11/19 Resident #1 was administered [MEDICATION NAME] 50mg as needed (PRN) pain medication for a total of fourteen (14) occurrences. Reassessment of pain medication effectiveness to monitor the Resident's response to the intervention was only completed for two (2) of the fourteen (14) administered doses of [MEDICATION NAME]. On 09/11/19 at 11:22 a.m. the Director of Nursing (DON) confirmed the Resident was not reassessed to evaluate the effectiveness of the administered [MEDICATION NAME]. The DON stated, I am calling in every nurse that administered those doses (of pain medication) and educating them. What else can I say, they didn't do it.",2020-09-01
3720,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2019-09-12,741,D,0,1,K00K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record, review, and staff interview the facility failed to provide non-pharmacological interventions before administering an antipsychotic medication to Resident #51 who was diagnosed with [REDACTED]. Resident identifier: # 51. Facility census 75. Findings included: a) Resident #51 Review of the resident's most recent Minimum Data Set (MDS) with an assessment reference date of 08/02/19, coded the resident as having physical behavior (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) as having occurred 4 to 6 times in the last 7 days but less than daily. Verbal behavior directed towards other, threatening screaming, and cursing as having occurred daily in the last 7 days Resident #51 has a [DIAGNOSES REDACTED]. A record review of Resident #51 medications revealed the resident had a current physician's orders [REDACTED]. The physician's orders [REDACTED]. PRN was renewed within 14 days as required by the regulations. The resident had orders for PRN [MEDICATION NAME] since at least 01/20/19. During an interview with the Director of Nursing (DON) on 09/10/19 at 11:52 AM, the DON stated the nursing staff were to conduct a pre-restraint assessment prior to giving [MEDICATION NAME]. The DON further noted on the pre-restraint assessment, the nursing staff have to indicate any non-pharmalogical interventions they attempted and / or provided the resident prior to administering the medication. A record review of Resident #51's [MEDICATION NAME] record for 08/11/19 to 09/10/19 revealed Resident #51 received 42 doses of [MEDICATION NAME] during the past 30 days. On 09/11/19 at 12:39 PM, an interview was conducted with the Assistant Director of Nursing (ADON). This surveyor and the ADON reviewed the [MEDICATION NAME] administration record from 08/11/19 to 09/10/19. The ADON examined the nurses notes as well as the pre-restraint assessment to reveal if any non-pharmalogical interventions were attempted prior to administering [MEDICATION NAME]. Per the ADON, the pre-restraint assessment is supposed to be completed before given this medication. The ADON also stated that the nursing staff may have documented in a nursing note whether non-pharmalogical interventions had been attempted prior to administering the medication to the resident. The ADON reviewed each date that was printed on the [MEDICATION NAME] administration report. Resident #51 received [MEDICATION NAME] 42 times during the timeframe of 08/11/19 to 09/10/19. The ADON could find 10 times that the facility could prove either by nurses notes or the pre-restraint assessment that Resident #51 was offered a non-pharmalogical interventions before giving the PRN [MEDICATION NAME]. The surveyor spoke with the DON on 09/11/19 at 01:07 PM concerning findings. No further information was provided.",2020-09-01
3721,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2019-09-12,755,E,0,1,K00K11,"Based on record review, staff interview, and observation the facility failed to maintain a secure storage method for controlled medications awaiting final disposition. This was a random opportunity for discovery with potential to affect more than a limited number of residents. Facility census: 75 Findings included: a) Controlled substance disposal storage On 09/10/10 at 1:52 p.m. Director of Nursing (DON) was asked to present the storage area for controlled medications awaiting final disposition. The DON then pointed out to a portable black plastic folding storage crate on wheels measuring approximately 18 x 18 x 20 inches. The storage crate was setting in the floor in the corner of her office and was verified by the DON as the designated storage area for the facility's controlled substances awaiting disposal. When the DON was asked if the storage crate was secure, affixed to the floor/wall and locked the DON replied, No, but my office door locks and the other door out there is locked after hours too. Access to a restroom from within the DON's office was noted, with entry to an adjoining office within the restroom. The DON confirmed the adjoining restroom to her office provided an open pathway for entry from the adjoining office and that the door was not locked at all times (and was not locked at the time of observation) and her office could be accessed through the restroom from the adjoining office. During the survey, the DON's office door was observed to be open at various times without her presence in the office, allowing access to the unsecure controlled medications. At 2:00 p.m. on 09/10/11 review of the contents of the black plastic portable storage crate revealed 74 medication cards (bubble packs) containing various controlled mediations awaiting destruction. Review of the Controlled Medication Destruction Log revealed the controlled medications had been removed from the facility's active medication supply as far back as 01/24/19 and were still awaiting destruction with no periodic reconciliation completed. The DON verified the last time any controlled medications were disposed of was 01/16/19, in which at that time all the controlled medications awaiting destruction for last year (2018) were disposed of. The facility's policy and procedure for Storage of Medication (revision date 05/09/18) stated: Compartments (including but not limited to, drawers, cabinets, room, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. The facility's policy for Storing of Controlled Medications (revision date 07/11/18) stated: The facility must store narcotics in separately locked, permanently affixed compartments. The facility's pharmacy services policy and procedure for Controlled Substance Storage declared the Schedule II-V (controlled) medications and other medications subject to abuse or diversion are to be stored in a permanently affixed double locked compartment. During an interview on 09/10/19 at 4:20 p.m. the DON stated, The pharmacist comes once a month, so we have the opportunity to destroy the medications, but I just have not done it yet. I haven't taken the time. The DON then further stated, I have moved the meds (medications) to the charge nurse's office where they are now locked in a metal file cabinet where they are secure.",2020-09-01
3722,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2019-09-12,758,D,0,1,K00K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement a Gradual Dose Reduction (GDR) for a [MEDICAL CONDITION] medication and a [DIAGNOSES REDACTED]. Resident identifier: #33. Facility census: 75. Findings included: a) Resident #33 On 09/10/19 at 12:05 PM, record review of the Resident's Plan of Care (P[NAME]) from 08/01/17 showed the Resident's 'Problems/Strengths' were Antipsychotic medication use, and antianxiety medication use, takes [MEDICATION NAME] for [MEDICAL CONDITION], [MEDICATION NAME] for anxiety. Mirtazepine for depression and Donepezil for Alzheimer's. On 07/07/16 the Resident was admitted to the facility with physician's orders [REDACTED]. To date the Resident has not been diagnosed with [REDACTED]. Record review of the Medication Record Review (MRR) dated 03/05/19 showed the Pharmacist recommended a GDR for [MEDICATION NAME]. Directions for the [MEDICATION NAME] 0.5 milligrams (mg) was Take 1 tablet twice daily for [MEDICAL CONDITION]. The physician disagreed with the Pharmacist's recommendation by checking a box on the MRR form which read Discontinuation likely will be harmful to resident and for others or it will disrupt their provision of care. On 09/11/19 at 3:47 PM, staff interview with the Director of Nursing (DoN) confirmed the physician had not attempted a GDR for [MEDICATION NAME].The DoN confirmed the resident has not had a GDR since she was admitted on [DATE] with the medication.",2020-09-01
4438,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2016-03-10,276,E,0,1,EQIS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument User's Manual - Version 3.0 (RAI Manual), and staff interview, the facility failed to complete quarterly minimum data sets (MDS) as specified by the State and approved by the Centers for Medicare and Medicaid Services (CMS). Quarterly assessments were not completed within fourteen (14) days of the assessment reference date (ARD) for four (4) of twenty-one (21) residents whose MDSs were reviewed during Stage 2 of the Quality Indicator Survey (QIS). This was true for Residents #95, #96, #72, and #92. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #95, #96, #72, and #92. Facility census: 96. Findings include: a) Resident #95 On 03/07/16 at 11:25 a.m., reconciliation of the current residents residing in the facility found Resident #95 was not on the list of residents who had resided or continued to reside in the facility. This resident had resided in the facility since admission date of [DATE]. Review of Resident #95's MDSs found an MDS with an ARD of 02/16/16, was incomplete in sections A, B, C, G, H, I, J, L, M, N, S, and Z. On 03/08/16 at 1:00 p.m., review of the MDS with the ARD of 02/16/16, found item Z0400, signed and dated on 02/26/16 by MDS Coordinator #78 to indicate sections A, B, C, G, H, I, J, L, M, N, and S were completed on 02/26/16. In addition, Item Z0500 - Signature of RN Assessment Coordinator Verifying Assessment Completion, was signed MDS Coordinator #78 on 02/26/16 to certify the assessment was complete. Review of the MDS assessment report for the MDS with the ARD of 02/16/16, found MDS Coordinator #78 had not completed sections A, B, C, G, H, I, J, L, M, N, S, and Z until 03/08/16 at 11:39 a.m. The MDS Coordinator had certified the assessment as complete and ready for submission on 03/08/16 at 12:24 p.m. According to the RAI Manual, Chapter 2, page 16, the assessment must be complete by fourteen (14) calendar days of the ARD date. Interview on 03/08/16 at 2:30 p.m., with MDS Coordinator #78 revealed she thought she had 28 days to complete, certify, and submit the MDS. On 03/08/16 at 3:15 p.m., during a review of the MDS with the ARD of 02/16/16 with the director of nursing (DON), she agreed the MDS should have been completed by 03/01/16. She also verified the MDS was completed on 03/08/16, not 02/26/16 as indicated in Section Z by MDS Coordinator #78. b) Resident #96 On 03/07/16 at 11:45 a.m., reconciliation of the current residents residing in the facility also found Resident #96 was not on the list of current residents. This resident had resided in the facility since admission on 02/02/01. Review of Resident #96's MDSs found an MDS with an ARD of 02/19/16. Sections A, B, C, G, H, I, J, L, M, N, S, and Z of this assessment were incomplete. On 03/08/16 at 3:30 p.m., the MDS with an ARD of 02/19/16 was reviewed with the director of nursing (DON). She agreed the MDS should have been completed by 03/04/16. She also verified the MDS remained incomplete at the time of the interview. c) Resident #72 Review of Resident #72's medical records on 03/08/16 at 12:30 p.m., found an MDS with an ARD of 02/19/16. This MDS was found to be incomplete in sections A, B, C, G, H, I, J, L, M, N, S, and Z. On 03/08/16 at 3:30 p.m., after review of the MDS with an ARD of 02/19/16 with the director of nursing (DON), she agreed the MDS should have been completed by 03/04/16. She also verified the MDS remained incomplete at the time of the interview. d) Resident #92 Record review at 10:00 a.m. on 03/09/16, found a quarterly minimum data set (MDS) with an assessment reference date (ARD) of 02/19/16. Sections J - Health conditions, L - oral/dental status, M - skin conditions, and N - medications had not been completed. The MDS should have been completed on 03/04/16.",2019-11-01
4439,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2016-03-10,278,D,0,1,EQIS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete assessments prior to signing and certify the minimum data sets (MDS) were complete. This was found for one (1) of twenty-one (21) residents whose MDSs were reviewed during Stage 2 of the Quality Indicator Survey (QIS). This was true for Residents #95. Additionally, for two (2) of five (5) resident's reviewed for the care area of unnecessary medication, Residents #76 and #90, the facility failed to completed accurate MDSs in regards to active [DIAGNOSES REDACTED]. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #95, #76, and #90. Facility census: 96. Findings include: a) Resident #95 On 03/07/16 at 11:25 a.m., reconciliation of the current residents residing in the facility found Resident #95 was not on the list of residents who had resided or continued to reside in the facility. This resident had resided in the facility since admission date of [DATE]. Review of Resident #95's MDSs on 03/08/15 at 1:00 p.m., found an MDS with an ARD of 02/16/16, was incomplete in sections A, B, C, G, H, I, J, L, M, N, S, and Z. Item Z0400, was signed and dated on 02/26/16 by MDS Coordinator #78 to indicate sections A, B, C, G, H, I, J, L, M, N, and S were completed on 02/26/16. In addition, Item Z0500 - Signature of RN Assessment Coordinator Verifying Assessment Completion, was signed MDS Coordinator #78 on 02/26/16 to certify the assessment was complete. Review of the MDS assessment report for the MDS with the ARD of 02/16/16, found MDS Coordinator #78 had not completed sections A, B, C, G, H, I, J, L, M, N, S, and Z until 03/08/16 at 11:39 a.m The MDS Coordinator had certified the assessment as complete and ready for submission on 03/08/16 at 12:24 p.m. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manuel, Chapter 2, page 16, the assessment must be complete by fourteen (14) calendar days of the ARD date. Interview on 03/08/16 at 2:30 p.m., with MDS Coordinator #78 revealed she thought she had 28 days to complete, certify, and submit the MDS. On 03/08/16 at 3:15 p.m., during a review of the MDS with the ARD of 02/16/16 with the director of nursing (DON), she agreed the MDS should have been completed by 03/01/16. She also verified the MDS was completed on 03/08/16, not 02/26/16 as indicated in Section Z by MDS Coordinator #78. b) Resident #76 A review of the medical record for Resident #76 on 03/08/16 at 2:21 p.m., revealed the quarterly MDS assessment with the assessment reference date (ARD) of 12/11/15 did not accurately reflect the [DIAGNOSES REDACTED]. During further review, it was noted in the physician's orders [REDACTED].#76 had orders for [MEDICATION NAME] 0.5 milligrams (mg) daily for anxiety and [MEDICATION NAME] 20 mg daily for GERD. A review of the Medication Administration Record [REDACTED]. In an interview on 03/09/16 at 3:32 p.m., the MDS Coordinator verified Section I - Active [DIAGNOSES REDACTED].#76. c) Resident #90 A review of the medical record for Resident #90 on 03/09/16 at 10:44 a.m., revealed the quarterly MDS assessment with the ARD of 12/28/15 did not accurately reflect the [DIAGNOSES REDACTED]. During further review, it was noted in the physician's orders [REDACTED].#90 had an order for [REDACTED]. An interview on 03/09/16 at 12:10 p.m., with the MDS Coordinator verified Section I - Active [DIAGNOSES REDACTED].#90.",2019-11-01
4440,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2016-03-10,280,D,0,1,EQIS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the care plan to reflect changes in condition for one (1) of four (4) residents reviewed for the care area of nutrition during the survey process. The care plan of Resident #68 was not revised after a significant weight loss. Resident identifier: #68. Facility census: 96. Findings include: a) Resident #68 This resident's record was reviewed for the care area of nutrition during Stage 2 of the QIS due to weight loss. Record review on 03/08/16 at 2:24 p.m., found this [AGE] year-old male resident was admitted to the facility with a gastrostomy tube feeding on 09/23/15. The following weights were obtained from the electronic medical record: -- 01/13/16 - 142.4# (pounds) -- 01/20/16 - 140.4# -- 01/27/16 - 138.6# -- 02/03/16 (the resident's medical record reflected two (2) weights-136.2# and 129.0# -- 02/10/16 - 130.5# -- 03/02/16 - 126.6# The resident had a 15.8# weight loss between 01/13/16 and 03/02/16. Further review of the medical record found the resident was noted to be combative with his bolus gastric tube feedings and had a history of [REDACTED]. The physician discontinued the bolus feedings and added continuous tube feedings. An abdominal binder was applied. On 02/15/16, the dietitian evaluated the resident and a supplement was added. A psychological consult was also ordered to address the resident's weight loss. Review of the resident's current care plan, dated 01/08/16, revised on 02/25/16, found a problem of, (Name of resident) receives a tube feeding. The goal associated with this problem was, Will remain at current weight plus or minus 3# in next three month period AEB (as evidenced by) recorded weights. Interventions included: -- Diet as ordered. -- Notify MD (doctor) as needed for weight changes or decreased intake. -- Flushes as ordered. -- Raise head of bed 30 during feeding. -- Monitor weight as ordered. -- Provide formula and rate as: [MEDICATION NAME] (high-protein, fiber fortified formula that provides balanced nutrition for long or short term tube feeding) 1.5 full strength, 22 hours on and 2 hours off. -- Assess tube-feeding orders for adequate daily intake of protein, calories, and fluids. At 3:12 p.m. on 03/08/16, Registered Dietitian (RD) #16 confirmed he had forgotten to update the care plan to reflect the resident's weight loss.",2019-11-01
4441,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2016-03-10,309,E,0,1,EQIS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure two (2) of four (4) residents reviewed for the care area of nutrition received the necessary care and services to maintain and/or attain the highest practicable level of well-being. Resident #93 and Resident #34 both had physician orders [REDACTED]. The facility failed to ensure they consumed fluids less than or equal too the ordered restriction on a daily basis. Resident identifiers: #93 and #34. Facility census: 96. Findings include: a) Resident #93 A review of Resident #93's medical record at 2:46 p.m. on 03/08/16, found a physician's progress note dated 12/17/15. This note indicated Resident #93's attending physician saw her on 12/17/15 and indicated the resident needed a work up for [MEDICAL CONDITION] ([MEDICAL CONDITION] is a condition that occurs when the level of sodium in the blood is abnormally low. Sodium is an electrolyte, and it helps regulate the amount of water that's in and around the cells) and that this condition was probably chronic and due to SIADH (syndrome of inappropriate antidiuretic hormone secretion). The attending physician indicated that he would start a fluid restriction and if the resident had any changes in her mental status, they would infuse urgently. Further review of Resident #93's medical record found a physician's orders [REDACTED]. (Please note one (1) ml equals one (1) cubic centimeter (cc).) Review of Resident #93's total fluid intake for 02/24/16 through 03/08/16 found the following dates when Resident #93 consumed more than 1000 ml per day: -- 02/26/16 she had a fluid intake of 1,340 cc which was 340 cc over her fluid restriction.-- 02/26/16 she had a fluid intake of 1,340 cc which was 340 cc over her fluid restriction. -- 02/27/16 she had a fluid intake of 1,220 cc which was 220 cc over her fluid restriction. -- 02/28/16 she had a fluid intake of 1,380 cc which was 380 cc over her fluid restriction. -- 03/01/16 she had a fluid intake of 1,240 cc which was 240 cc over her fluid restriction. -- 03/02/16 she had a fluid intake of 1,280 cc which was 280 cc over her fluid restriction. -- 03/03/16 she had a fluid intake of 1,200 cc which was 200 cc over her fluid restriction. -- 03/04/16 she had a fluid intake of 1,400 cc which was 400 cc over her fluid restriction. -- 03/08/16 she had a fluid intake of 1,560 cc which was 560 cc over her fluid restriction. An interview with the License Dietitian at 8:43 a.m. on 03/09/16, confirmed Resident #93 was on a fluid restriction of 1,000 ml per day. He indicated they had a breakdown of what fluids to send to the resident on her meal trays. Upon request, the Licensed Dietitian provided a sheet of paper with Resident #93's name on it which indicated she she would receive daily from the dietary department, Breakfast -- Whole Milk 240 cc -- Coffee 240 cc, Lunch -- Whole Milk 240 cc, and Dinner -- While Milk 240 cc. Fluid Total = 960 cc. The Licensed Dietitian said nursing would provide the remaining 40 cc of fluid daily. An interview with Licensed Practical Nurse (LPN) #22 at 9:49 a.m. on 03/09/16, confirmed she was the nurse assigned to care for Resident #93 on that date. She indicated the resident was on a 1000 cc fluid restriction. When asked how much of that fluid nursing was to provide to the resident, and how much Resident #93 was to receive with each one of her medication passes, LPN #22 went to speak with Health Service Worker (HSW) #51 and HSW #45 about how much fluid Resident #93 received on her breakfast and lunch trays. HSW #51 and #45 agreed that Resident #93 received milk and coffee on her breakfast and lunch trays. They indicated she would usually drink both the milk and coffee for a total of 480 cc for each meal. HSWs #51 and #45 did not know what fluids Resident #93 drank with her dinner meal. When asked if Resident #93 ever asked for any additional fluids to drink, LPN #22, HSW #51, and HSW #45 all agreed the resident only drank what was provided to her with her meals and what was given with her medication administrations. LPN #22 was again asked how much fluid she provided Resident #93 with her medications every morning, to which she replied, She hardly even takes any water to take her medications it is not even enough to count. During an interview with the Director of Nursing (DON) at 2:10 p.m. on 03/09/16. she was asked to review Resident #93's fluid intakes for 02/24/16, 02/27/16, 02/28/16, 03/01/16, 03/02/16, 03/03/16, 03/04/16, and 03/08/16. Upon completion of her review, she confirmed Resident #93 exceeded her fluid restriction on those dates. She stated, It is a problem we need to fix. . b) Resident #34 Record review on 03/09/16 at 8:15 a.m. found this fifty-five (55) year old male resident received outpatient [MEDICAL TREATMENT] services. His admitting [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. Review of the medical record found a physician's orders [REDACTED]. (Nepro supplement is a drink that helps support nutritional needs while on [MEDICAL TREATMENT].) The resident was receiving the supplement at 10:00 a.m., 2:00 p.m., and at bedtime. The orders did not specify the amount of fluid to be provided by the dietary and nursing departments. At 9:19 a.m. on 03/09/16, the facility's form entitled, 24 hour I & O (intake and output) worksheet, for 03/07/16, was reviewed with the facility's nutritionist, Registered Dietitian (RD) #16. Review of the worksheet for 03/07/16 found the health services workers (HSWs) recorded 720 cubic centimeters (cc) of fluid on the day shift, 720 cc of fluid on the afternoon shift and 360 cc of fluid on the night shift - for a total of 1800 cc in a twenty-four (24) hour period. RD #16 said the resident was only allowed 1500 cc of fluid in a twenty-four (24) hour period and he confirmed the resident had exceed his daily allowable amount of fluid for 03/07/16. At 9:27 a.m., on 03/09/16, an interview with HSW #111, found she was unaware of how much fluid Resident #34 could have in a twenty-four (24) hour period. (RD #16 was present during the interview.) HSW #111 said she recorded the fluid on the I & O forms, but she would have to look to see how much fluid the resident could have. After review of the instructions provided to the HSWs, HSW #111 provided a copy of a, confidential ad hoc summary, which included, Additional diet order: 1.5 L/day fluid restriction (not to include Nepro supplement). The instructions were dated 08/07/14. When asked how many cc of fluids were in a liter, HSW #111 said she did not know. RD #16 said a conversion sheet should have been available for the health services workers and confirmed a conversion sheet was not available for Resident #34. RD #16 said he did not know how many cc of fluid was allowed for the resident's medication pass. At 10:01 a.m. on 03/09/16, Licensed Practical Nurse (LPN) #63, the resident's nurse, was asked how much fluid she provided with her medication pass. She stated she really did not know, but probably a few sips, but sometimes the resident drank more. She said if it were a significant amount, she would tell the HSW so the fluid could be recorded. She defined a significant amount as 120 cc or more. At 10:09 a.m. on 03/09/16, Assistant Director of Nursing (ADON) #44 said she was unaware the health service workers did not have a, sheet available that tells them how many cc of fluid the resident can have on each shift. ADON #44 reviewed the resident's fluid intake for 03/04/16, 03/05/16 and 03/06/16. She verified the following information: -- On 03/04/16, the resident consumed 1830 cc of fluid in 24 hours, -- On 03/06/16, day and night shift failed to record the cc of fluid consumed. -- On 03/05/16, day shift did not record the resident's fluid consumption. At 10:25 a.m. on 03/09/16, ADON #44 confirmed the facility was not following the physician's orders [REDACTED]. On 03/09/16, at 9:35 a.m., the director of nursing (DON) confirmed the facility had reviewed the fluid restriction orders with the resident's physician and the physician had discontinued the fluid restrictions for Resident #34.",2019-11-01
5687,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2015-01-14,248,D,0,1,RMOB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observation, and record review, the facility failed to provide a meaningful activity program for one (1) of three (3) residents reviewed for activities. The Stage 2 sample was 28. Resident identifier: #40. Facility census: 89. Findings include: a) Resident #40 Resident #40 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. His most recent Minimum Data Set (MDS) assessment, dated 11/12/14, documented Resident #40 had short term and long term memory loss and was moderately cognitively impaired for daily decision making. The MDS also documented the resident was at times resistant to care and would wander on the unit. Review of the annual MDS, dated [DATE], found Resident #40 was assessed to enjoy being around animals, liked books, reading, keeping up with the news, and religious activities. The current care plan, dated 11/26/14, documented Resident #40 enjoyed church and coloring books. The care plan also documented the resident was not able to voice his choice regarding activities; therefore, staff were to anticipate his activity needs, inform him of scheduled activities, encourage him to participate, inform him when church services were being conducted, and escort him if needed. Review of the activity calendar for (MONTH) (YEAR), found on 01/12/15 at 3:00 p.m. and on 01/13/15 at 10:30 a.m., individual and small group activities were to take place on the individual resident units. Observations on these dates and times identified there were no activities conducted on C Unit due to the fact the activity staff for the C unit had called in ill. Further review of the (MONTH) activity calendar revealed Church services were offered on 01/04/15, 01/08/15, and 01/11/15. There was no evidence Resident #40 attended Church services on any of those dates. The activity calendar also indicated one-on-one activities were to be conducted on the individual units on 01/05/15, 01/07/15, and 01/12/15. There was no evidence Resident #40 was invited or attended these activities. Observations on 01/12/15 at 9:30 a.m., 1:10 p.m., and 3:30 p.m., revealed Resident #40 was in his wheelchair on the unit, but was not participating in any activities. Observation on 01/13/15 at 2:05 p.m. revealed he was in bed. Observation on 01/14/15 at 9:30 a.m. revealed he was in his wheelchair on the unit. Interview with Health Service Trainee #141, on 01/13/14 at 2:40 p.m., revealed she was not aware of any activities that occurred on the unit that Resident #40 attended. She stated she had never seen Resident #40 leave the unit during her shift from 7:00 a.m. until 3:00 p.m. to attend activities. She also stated she had never seen the activity staff come to the unit and do one-on-one activities with Resident #40. She stated he usually spent the day in his wheelchair or in his bed. She said he was mobile in his chair, but stated she was not aware of any activities he was involved in throughout the day. Interview with Activity Staff #129, on 01/13/15 at 2:05 p.m., revealed she was not the staff member responsible for providing one-on-one activities for the residents on the C unit. She indicated Activity Staff #29 was responsible for that unit, but he was off work ill on this date. She stated he called in ill yesterday and 01/13/15 was his day off. She stated she was aware Resident #40 liked to be read to, drink his coffee, and reminisce. Upon request to see the activity logs for Resident #40, she stated they did not keep good records of what they did for the residents in regards to one-on-one activities. She stated if the resident attended large group activities she would have documentation of that participation. She was not able to provide any documentation of one-on-one or any activities that were provided to Resident #40 on the unit, or off the unit, for (MONTH) 2014 or (MONTH) (YEAR). She stated she used to document on a standard form for individual resident participation when she conducted one-on-one activities with residents, but she did not document on that form anymore. Therefore there was no evidence of one-on-one activities participation for residents. Further interview with Activity Staff #129 on 01/14/15 at 3:22 p.m. revealed if an activity staff member was ill and could not provide the scheduled activities for their designated unit, the other activity staff did not cover that unit. She stated Activity Staff #29 had been off for three (3) days so the residents on the C units who were to receive one-on-one activities would not have received activities for those days. Activity Staff #129 said the only time activity staff would cover each other's units would be if an activity staff member was going to be off for an extended amount of time. This information was shared with the Director of Nursing Staff #6 on 01/14/15 at 9:08 a.m. She verified activity staff should be recording any activities provided to the residents. She also verified if an activity staff member was ill, another activity staff member should be covering that unit to ensure the residents were provided meaningful activities according to their care plans.",2018-09-01
5688,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2015-01-14,280,D,0,1,RMOB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to review and revise a nutrition care plan for one (1) of fifteen (15) residents whose care plans were reviewed. The Stage 2 sample was 28. Resident identifier: #66. Facility census: 89. Findings include: a) Resident #66 Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/02/14, found Resident #55 required assistance from staff for set up of his meals and he was to be supervised during meals. This MDS also documented the resident's Brief Interview for Mental Status score was 0, indicating cognitive impairment. He was also noted to reject care from the staff daily. Review of the nutrition care plan, dated 10/16/14, revealed Resident #66 required a textured diet, staff were to honor his food preferences, were to monitor food and meal intake, and were to offer alternatives for foods he refused to eat. Review of the nurse aide documentation for meal intake revealed Resident #66 had often been refusing to eat. Review of the food intake log for Resident #66 revealed on 12/04/14, 12/05/14, 12/06/14, 12/07/14, 12/31/14, and 01/12/15 he refused his breakfast and his lunch. In addition, the food intake log also revealed on 12/03/14, 12/04/14 and 12/09/14 he also refused to eat his supper. On these dates of refusal, there was no evidence staff offered him a supplement of any kind. Further review of the dietary food intake log revealed during the months of (MONTH) 2014 and (MONTH) 2014, there were greater than 50 meals where staff documented the resident consumed less than 50% of his meal. Interview with Health Service Worker (HSW) #147, on 01/13/15 at 10:20 a.m., revealed Resident #66 had been refusing to eat meals lately and when he did eat, it was often less than 50%. She stated he would not allow the staff to assist him to eat, but they did cue him to eat when he refused. She stated she was not aware of any ordered supplements that the resident was currently receiving. Review of the weight log for Resident #66 revealed the following: -- On 01/06/2015 weight was recorded as 133 pounds -- On 10/03/2014 weight was recorded as 152 pounds -- On 08/05/2014 weight was recorded as 143 pounds These documented weights indicated Resident #66 had experienced a 19 pound weight loss (or 14.3%) from 10/03/14 to 01/06/15. There was no evidence the nutrition care plan had been reviewed or revised to include new interventions to address Resident #66's weight loss of 19 pounds over the past 4 months. This was verified during an interview with the Dietary Manager Staff #47 on 01/13/14 at 10:55 a.m. He verified he had documented the weight difference for Resident #66 from the 10/03/14 weight of 152 pounds to the 01/06/15 weight of 133 pounds, but stated somehow it was not picked up and acted upon with new interventions to prevent further weight loss for Resident #66.",2018-09-01
5689,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2015-01-14,282,D,0,1,RMOB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and observations, the facility failed to implement the care plans for two (2) of fifteen (15) residents whose care plans were reviewed. Activities interventions were not implemented for Resident #41 and fall interventions were not implemented for Resident #15. The Stage 2 Sample was 28. Resident identifiers: #40 and #15. Facility census was 89. Findings include: a) Resident #40 Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his most recent Minimum Data Set (MDS) assessment, dated 11/12/14, found it documented Resident #40 had short term and long term memory loss and was moderately cognitively impaired for daily decision making. The MDS also documented the resident was at times resistant to care and at times and would wander on the unit. Review of the annual MDS, dated [DATE], found Resident #40 enjoyed being around animals, liked books, reading, and keeping up with the news and religious activities. Review of the current care plan, dated 11/26/14, found it documented Resident #40 enjoyed church and coloring books. The care plan also documented the resident was not able to voice his choice regarding activities, therefore staff were to anticipate his activity needs, inform him of scheduled activities, encourage him to participate, and to inform him when Church services were conducted and escort him if needed. Review of the activity calendar for (MONTH) (YEAR) revealed on 01/12/15 at 3:00 p.m. and on 01/13/15 at 10:30 a.m., the activity calendar identified individual and small group activities were to take place on the units. According to observations on these dates and times, there were no activities conducted on C unit due to the fact the activity staff for the C unit had called in ill. On 01/13/15 at 10:30 a.m., the activity calendar indicated individual and small group activities were to take place on the units. There were no activities observed being provided at that time. Review of the (MONTH) (YEAR) activity calendar revealed Church services were offered on 01/04/15, 01/08/14, and 01/11/15. There was no evidence Resident #40 attended Church service on any of those dates. The activity calendar also indicated one-on-one activities were to be provided on the unit on 01/05/15, 01/07/15, and 01/12/15. There was no evidence Resident #40 was invited or attended these activities. Observations on 01/12/15 at 9:30 a.m., 1:10 p.m., and 3:30 p.m. revealed Resident #40 was in his wheelchair on the unit, but was not participating in any activities. Observation on 01/13/15 at 2:05 p.m. revealed he was in bed. Observation on 01/14/15 at 9:30 a.m. revealed he was in his wheelchair on the unit An interview with Health Service Trainee #141 on 01/13/14 at 2:40 p.m. revealed she was not aware of any activities that occurred on the unit that Resident #40 attended. She stated she had never seen Resident #40 leave the unit during her shift from 7:00 a.m. until 3:00 p.m. to attend activities. She also stated she had never seen activity staff come to the unit and do one-on-one activities with the resident. She stated he usually spent the day in his wheelchair or in his bed. She said he was mobile in his chair, but stated she was not aware of him being involved in any type of activities. Interview with Activity Staff #129, on 01/13/15 at 2:05 p.m., revealed she was not the staff member responsible for providing one-on-one activities for the residents on the C unit. She indicated Activity Staff #29 was responsible for Unit C activities, but he had been off for the past three (3) days. She stated she was aware Resident #40 liked to be read to, drink coffee, and reminisce, but she was unable to provide activity logs that documented these actives were provided to Resident #40 in accordance with his current activity care plan. She stated she used to document on a standard form for individual resident participation when she conducted one-on-one activities with resident, but she did not document on that form anymore. Therefore, there was no evidence of Resident #40 attending any activities in (MONTH) 2014 or (MONTH) (YEAR) in accordance with his current care plan. This information was shared with the Director of Nursing Staff #6 on 01/14/15 at 9:08 a.m She verified activity staff should be recording any activities provided to the residents. She also verified activities should ensure the residents were provided meaningful activities in accordance with their care plans. . b) Resident #15 Resident #15 was admitted with [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set, dated dated [DATE], indicated the resident had severely impaired cognition. The resident required limited assistance with transferring and walking in his room. He was independent with locomotion on and off the unit. A review of the nursing notes indicated Resident #15 had a fall on 01/03/15. The resident was ambulating without assistance and fell to the floor. A review of Resident #15's physician's orders [REDACTED]. A review of the resident's care plan, dated 06/04/14, and last reviewed by the facility on 12/09/14, found Resident #15 was identified as At risk for fall and injury related to impaired cognition, impaired mobility and [MEDICAL CONDITION] drug use, and [MEDICAL CONDITION]. The interventions included, Hipsters at all times due to high fall risk, unsteadiness on his feet, not asking for assistance and non-compliant with alarms. During an interview and observation on 01/14/15 at 9:30 a.m., Health Service Trainee (HST) #137 was questioned about the resident's fall interventions. She stated the resident was supposed to wear hipsters at all times. She looked in the resident's dresser for the hipsters. The hipster was a tan colored undergarment with padding at the hip area. She indicated the hipsters were worn under his clothing, on top of his incontinence brief. HST #137 checked Resident #15 and found he was not wearing the hipster. She stated the night shift usually got him dressed. She indicated she had not noticed he was not wearing the hipster that morning. During an interview on 01/14/15 at 9:45 a.m., HST #68 was questioned about the resident's fall interventions. She indicated the resident was supposed to wear hipsters every day because he was at risk for falls. She stated he had three (3) or four (4) pairs. She said on the weekends, they ran out of the hipsters because they were sent to the laundry for cleaning. She added the laundry staff did not work on the weekends, and they had to wait until Monday to get the hipsters cleaned. She stated on Sundays, when she dressed the resident, he usually did not have any hipsters. HST #68 stated she had asked laundry for extra pairs, but did not always get the hipsters. HST #68 indicated if she was working on Fridays, then she asked the laundry staff to clean the hipsters to ensure he had enough for the weekend. During an interview on 01/14/15 at 10:05 a.m., Laundry Worker #23 stated sometimes the staff called on Friday and asked for more hipsters. She indicated on Fridays, laundry staff delivered all the residents' clothing on all the units. She stated Resident #15 had two (2) to three (3) pairs of hipsters sent to laundry every day to be washed. She stated they kept an inventory log of the resident's hipsters. She said she was returning all of Resident #15's hipsters from the laundry at that time. A review of Resident #15's Clothing/Inventory List, indicated on 12/31/12, the resident had two (2) pairs of hipsters. On 04/28/14, the resident had three (3) pairs of hipsters. During an observation and interview on 01/14/15 at 10:26 a.m., HST #68 checked the resident's room, and indicated he had four (40 pairs of hipsters. He had three (3) pairs in his dresser, and he was currently wearing a pair of hipsters. During an interview with the Director of Nursing on 01/14/15 at 10:55 a.m., she stated she had not been informed and was not aware that the resident was running out of hipsters over the weekend. The staff had not reported the concern of the lack of availability of hipsters for Resident #15 on the weekends.",2018-09-01
5690,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2015-01-14,325,G,0,1,RMOB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure one (1) of (4) residents reviewed for nutrition was provided care and services to maintain acceptable parameters of nutritional status. Resident #66 experienced a severe weight loss of 14.3% in three (3) months. Documentation revealed the resident frequently refused meals in the two (2) months prior to the time the resident's recorded weight indicated a severe weight loss. The weight loss was determined actual harm as there was no evidence the weight loss was assessed for causal factors, and no evidence substitutes were offered when the resident refused meals. In addition, there was no evidence the facility attempted to provide any interventions to prevent further weight loss. The Stage 2 Sample was 28. Resident identifier: #66. Facility census: 89 residents. Findings include: a) Resident #66 Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/02/14, found the resident required assistance from staff to set up his meals and he was to be supervised during meals. This MDS also documented the resident's Brief Interview for Mental Status score was 0 indicating cognitive impairment. He was also noted to reject care from the staff daily. Review of the nutrition care plan, dated 10/16/14, revealed Resident #66 required a textured diet, staff were to honor his food preferences, monitor food and meal intake, and were to offer alternatives when he refused to eat. Review of the dietary progress notes revealed there were only two (2) progress notes for the year 2014. The last note, documented on 11/17/14, indicated Resident #66 had gained weight, but the weight gain was not significant and was more desirable than undesirable. There were no dietary progress notes found after Resident #66 was identified, on 01/06/15, as experiencing a 19 pound weight loss from (MONTH) 2014 until (MONTH) (YEAR). Review of the nurse aide documentation for meal intake revealed Resident #66 often refused to eat. Review of the food intake log for Resident #66 revealed on 12/04/14, 12/05/14, 12/06/14, 12/07/14, 12/31/14, and 01/12/15 Resident #66 refused his breakfast and his lunch. On 12/03/14, 12/04/14, and 12/09/14, he also refused to eat his supper. On these dates of refusal, there was no evidence the staff offered him a supplement of any kind. Further review of the dietary food intake log revealed, during the month of (MONTH) 2014 and (MONTH) 2014, there were greater than 50 meals where staff documented the resident consumed less than 50% of his meal. There was no evidence the staff had offered him any substitutes or supplements. Review of the current physician orders [REDACTED]. Review of the weight log for Resident #66 revealed the following: -- On 08/05/14 weight was 143 pounds -- On 10/03/14 weight was 152 pounds -- On 01/06/15 weight was 133 pounds These documented weights indicated Resident #66 had experienced a 19 pound, or 14.3%, weight loss from 10/03/14 to 01/06/15. According to nursing documentation, in (MONTH) 2014 and (MONTH) 2014 there were greater than 50 meals when the resident consumed less than 50%, observation of lunch, on 01/13/15 at 12:05 p.m., revealed Resident #66 fed himself 100% of his meal with no staff cueing. He was served chopped meat and two (2) types of vegetables, milk, juice, and water. Interview with Health Service Worker (HSW) #147, on 01/13/15 at 10:20 a.m., revealed Resident #66 had been refusing to eat meals lately, and when he did eat, it was often less than 50%. She stated he would not allow the staff to assist him to eat, but they did cue him to eat when he refused. She stated she was not aware of any ordered supplements the resident was currently receiving. Interview with Dietary Manager #47, on 01/13/14 at 10:55 a.m., revealed he had documented the weight difference for Resident #66 from the 10/03/14 weight of 152 pounds to the 01/06/15 weight of 133 pounds. He stated somehow this weight loss was not acted upon when he conducted his weekly review of residents with weight loss. He was not able to explain why this identified weight loss for Resident #66 was not addressed and interventions put into place to ensure no further weight loss occurred. He stated it could be that the weight obtained on 01/06/15 was inaccurate and he would have the staff re-weigh the resident. This surveyor observed the resident being re-weighed on 01/13/14 at 11:15 a.m. The weight was 133 pounds. Dietary Manager #47 stated this was the same weight that he had documented on 01/06/15. The dietary manager stated he should have acted on the identified weight loss at that time. He stated he spoke with health service worker staff after the resident was re-weighed. They advised him that the resident had not been eating well lately and had been refusing meals more often. Further interview with Dietary Manager #47 revealed he would be putting new interventions into place, on this date, to include notifying the physician to attempt to get an appetite stimulant and he was also going to obtain an order for [REDACTED]. On 01/13/15 at 1:22 p.m., the director of nursing (DON) described the procedure for how weights were obtained and reported to the dietary staff. The DON said the Health Service Workers obtained the weights and documented them in the computer. The assistant director of nursing (ADON) then compared the weight to the previous weight. If a loss was noted, the ADON would send a consultation request to the dietary manager. She stated the ADON had been off since (MONTH) 2014 on maternity leave. The DON said she had been trying to cover this process, but somehow the identification of weight loss for Resident #66 was missed.",2018-09-01
7236,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2014-07-23,164,D,1,0,R9GB11,"Based on observation and staff interview, the facility failed to ensure one (1) resident identified through random observation was treated in a manner that maintained the resident's privacy during toileting. Resident #34 was being assisted in the bathroom by a health service worker (HSW). The HSW failed to ensure the bathroom door was closed, leaving the resident exposed below the waist. Resident identifier: #34. Facility census: 94. Findings include: a) Resident #34 During random observations in the C North Area Day Room at 4:08 p.m. on 07/22/14, a resident pointed to the bathroom door. Resident #34 was standing in the bathroom facing the bathroom door which opened into the C North Day Room. The resident was unclothed from the waist down. A licensed practical nurse (LPN) #107 was nearby and was asked to look into the bathroom at 4:09 p.m. on 07/22/14. She immediately went into the bathroom and closed the door. When she returned from the bathroom she was asked whether Resident #34 had gone into the bathroom alone. She stated, No, a health service worker (HSW) was in there with him. She indicated Resident #34 needed assistance toileting. When asked if the HSW should have assisted the resident with his toileting needs with the door open she replied, No, absolutely not.",2017-07-01
7237,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2014-07-23,282,D,1,0,R9GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident observation, the facility failed to implement the care plan for one (1) of five (5) residents. Resident #43 had a care plan intervention and physician's orders [REDACTED]. Upon observation, Resident #43 did not have a personal alarm in use. Resident identifier: #43. Facility census: 94. Findings include: a) Resident #43 A review of Resident #43's care plan at 12:15 p.m. on 07/21/14, found an intervention of, Use personal alarm in wheelchair to alert staff of need of assistance. This intervention was added to Resident #43's care plan on 07/10/14. An observation of Resident #43, at 10:06 a.m. on 07/22/14, found the resident sitting in the D West Day Lounge in her wheelchair. Resident #43's personal alarm was not observed in use at that time. At 10:10 a.m. on 07/22/14, Licensed Practical Nurse (LPN) #25, was asked whether Resident #43 should have a personal alarm in use. She replied, Yes, she should. She then observed Resident #43 and stated, I will have to go and get an alarm to put on her because she currently does not have one in place. During an interview at 10:15 a.m. on 07/22/14, the director of nursing confirmed the physician's orders [REDACTED].#43 indicated the resident was to have a personal alarm on at all times when in her wheelchair. After this confirmation, the DON excused herself and stated, I really need to go get an alarm and put it on her.",2017-07-01
7238,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2014-07-23,323,G,1,0,R9GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident environment was as free from accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents. This was true for one (1) of five (5) sampled residents reviewed for accidents Resident #43 was identified at a high risk for falls on admission. The facility failed to implement interventions to reduce the resident's risk of falling and/or reduce risk of injury should a fall occur, until after the resident experienced a fall resulting in a nasal fracture, a closed head injury, and a cervical strain. This failure resulted in actual harm to Resident #43. Resident Identifier: #43. Facility Census: 94. Findings Include: a) Resident #43 Review of the facility's incident and accident reports, at 12:00 p.m. on 07/21/14, revealed on 07/05/14 at 12:55 p.m., while sitting near the nurses' desk, Resident #43 fell forward out of her wheelchair and landed on the floor. The report indicated the resident possibly had become tired and sleepy. The report also noted the resident had a very long torso and had a thick cushion on the seat of her wheelchair. A review of Resident #43's medical record, at 12:15 p.m. on 07/21/14, revealed a Fall Risk Evaluation was completed on 06/25/14, the date of the resident's admission to the facility. According to the assessment's scoring criteria, any score above a 10 represented high risk. The resident's score was 14. Nurse's progress notes, dated 06/25/14, revealed nursing staff were made aware the resident was at high risk for falls. The note was (typed as written): Rsdt has fall score of 14. Review of the minimum data set assessment (MDS), with an assessment reference date (ARD) of 07/03/14, indicated the resident's Brief Interview for Mental Status (BIMS) score was 6, indicating severe cognitive impairment. The assessment indicated the resident did not walk and was only able to stabilize with human assistance in moving from a seated to standing position. She had impairment in functional range of motion of one upper extremity and both lower extremities. The assessment indicated the resident had experienced a fall in the month prior to admission. In addition, the MDS indicated the resident took 1-2 medications which could increase her risk of falls, and had 1- 2 predisposing diseases which also could increase her risk for falls. On 07/05/14 at 1:12 p.m., a nurse's note indicated (typed as written): Resident was sitting in her wheelchair on the unit when she fell forward onto the floor at approximately 1:00 p.m. Hematoma noted on mid forehead and laceration across the bridge of her nose. Resident alert. Eyes open. Moaning quietly. (Name of Registered Nurse) present and assessed resident. Directed to send to ER (emergency room ). ER notified of resident's condition and need for transfer for evaluation. EMS notified. Arrived at 1:20 p.m. Left with resident at 1:28 p.m. en route to (name of local hospital) ER. Review of the resident's ER records revealed Resident #43 was treated for [REDACTED]. She was not admitted to the hospital and returned to the facility later in the day on 07/05/14. According to the nursing home medical record, the resident's cushion was removed from her chair immediately after the fall because it was identified as a contributing factor. Additionally, the facility ordered a personal alarm for the resident to use while in her wheelchair. These interventions were put into place only after the resident sustained [REDACTED]. In an interview with the Director of Nursing (DON) at 10:15 a.m. on 07/22/14, she confirmed the fall assessment completed on the date of admission indicated Resident #43 was at high risk for falls. When asked what interventions or further assessments the facility did when the resident was identified as a high risk for falls, the DON stated, She was a two person assist for transfers and that is all I see. The DON stated they felt Resident #43's cushion in her wheelchair was the cause of her fall. She stated the resident brought the cushion from home and was admitted with it. The DON was asked who evaluated the residents for proper positioning in their wheelchairs. She said occupational therapy (OT) usually did that. She said a consult request was made to OT upon the resident's admission on 06/25/14, and again on 07/01/14. The DON acknowledged the OT evaluation did not occur until 07/11/14, six (6) days after the resident's fall with injury. When asked why it took OT so long to evaluate the resident, she replied, They don't actually work here and only come in about once every two (2) weeks. When the OT screened the resident, on 07/11/14, she noted the resident leaned forward in her wheelchair with two (2) degrees of kyphosis (curving of the spine). This would have been information the facility should have known, prior to the fall, particularly with the resident's long torso and use of a cushion in the wheelchair. The OT also noted the use of a personal alarm would be beneficial due to the fact the resident leaned forward in her wheelchair. This intervention for a personal alarm was put into place only after the resident sustained [REDACTED]. Prior to 07/05/14, the facility had already identified the resident at high risk for falls; however, no interventions were developed in an effort to prevent falls. During the interview at 10:15 a.m. on 07/22/14, the DON was asked why no interventions were put into place for Resident #43 when she was assessed upon admission at high risk for falls. The DON replied, Not everyone who is at high risk for falls needs interventions. The DON agreed the facility should have put fall interventions into place prior to the 07/05/14 incident. She agreed the facility's knowledge of a fall assessment at the time of admission and the resident's prior history of falls made it necessary for the facility to put interventions in place to try to prevent future falls and injuries associated with falls. She confirmed the facility had not put those interventions in place prior to the fall on 07/05/14.",2017-07-01
7328,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2013-10-22,157,D,0,1,TQVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, and policy review, the facility failed to notify the physician when one (1) of two (2) residents reviewed for accidents during Stage 2 of the Quality Indicator Survey had an accident which resulted in injury and required medical intervention. The physician was not notified when the resident burned herself with a cigarette. Resident identifier: #38. Facility census: 87. Findings include: a) Resident #38 Medical record review, on 10/17/13 at 8:00 a.m., found a nursing note dated 09/23/13 at 1:20 p.m. which indicated when Resident #38 returned to the facility after a smoke break she had an orangish/black burn mark on her right middle finger. Further review of the medical record found no evidence the physician was notified of the injury. The resident confirmed, during an interview on 10/21/13 at 12:39 p.m., she had burned her finger while she was outside smoking. She said, The nurse treated it with burn cream. Employee #179, a licensed practical nurse (LPN) was interviewed on 10/21/13 at 12:50 p.m. She said she was not aware of a burn, but had noted brown nicotine stains on the resident's fingers. Another LPN, Employee #27, was interviewed on 10/22/13 at 12:50 p.m. She said she was aware of the burn / injury. Employee #27 stated the resident's burn was treated with triple antibiotic ointment. She related the protocol was to complete an incident report and to notify the physician. The LPN reviewed the medical record, including physician's orders [REDACTED]. She confirmed there was no evidence to indicate the physician was notified. The policy book, dated 2005, was reviewed with the director of nursing (DON) at 3:00 p.m. on 10/17/13. The DON confirmed a report was to be generated for each and every event/accident, and routed to the medical director for review/signature/date and /or investigation. The DON was unable to find the report which should have been generated after the resident's burn. The DON further reviewed physician's orders [REDACTED]. She acknowledged she was unable to find any evidence the physician was notified the resident burned herself with a cigarette and facility staff had treated the burn with triple antibiotic ointment. .",2017-06-01
7329,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2013-10-22,241,E,0,1,TQVD11,"Based on observation and staff interview, the facility failed to maintain a dignified dining experience for residents. Meal service in several dining rooms was observed during the survey with the following concerns noted: one dining area smelled of cigarette smoke; there was no opportunity for hand cleansing prior to the meal; Resident #84 was seated at a table with three (3) other residents, but did not receive her meal until 30 minutes after her table mates; residents were seated in the dining room for an extended period of time before arrival of their meals with no pre-meal activities offered; Resident #91 stood up and said she needed to go to the bathroom, but did not receive prompt assistance to go to the bathroom; Resident #56 attempted to leave the dining room, but a staff member pulled the resident backwards, returned the resident to the table, all without speaking to the resident. This practice had the potential to affect all residents who received meals in the dining rooms. Resident identifiers: #84, #56, #91, and #78. Facility census: 87. Findings include: a) Dining room C-West Observation of the C-West dining room began at 4:35 p.m. on 10/15/13. The following were noted: -- The dining room smelled of cigarette smoke. Not all residents who ate in the dining room smoked, nor could they express whether they objected to the smoke smell. -- Residents waited for approximately 45 minutes before the first tray was served at 5:26 p.m. During this wait, there were no pre-meal activities. During the evening meal on 10/15/13, Employee #180, a health services worker was asked if there were any pre-meal activities. Employee #180 replied, It would be nice, but only fine dining gets that. -- There was no opportunity provided for residents to cleanse their hands. Some residents were brought in by staff, some walked in, and others wheeled themselves in to the rooms. Many of the residents had been in the halls for an extended period of time prior to going to the dining room and did not have access to a sink to wash their hands prior to going to meals. Some of the residents who wheeled themselves into the dining room, had used their hands to propel their wheelchairs and needed to be afforded the opportunity to clean their hands before eating. It was observed that staff cleaned their own hands with hand sanitizer, but did not provide residents with an opportunity to clean their hands before the dinner meal was served. A second meal observation was made during the noon meal on 10/17/13. Residents were seated in the dining room and waited approximately 40 minutes before the arrival of the trays at 12:02 p.m Again there were no pre-meal activities, no hand sanitation for residents, no beverages were offered (pre-meal) and the odor of cigarette smoke was strong. b) Dining room B-D Observation of the evening meal on 10/15/13 at 5:14 p.m. in the, B-D dining room found residents were not offered hand wipes or any means by which to wash their hands prior to the meal. This procedure did not enhance the residents' dignity during meals by allowing them to eat with unclean hands. This observation was discussed with the director of nursing, Employee #6, on the morning of 10/22/13 at which time she was in agreement that residents should be afforded the opportunity to wash their hands prior to meals. c) Dining room AC An observation was conducted in the AC dining room on 10/15/13 at 5:30 p.m. Resident's #1, #19, #84, and #88 were all seated at the same table. All four (4) of these residents required total assistance with eating. Resident's #1, #19, and #88 were served their trays at 5:30 p.m. and were being fed by Employees #40, #77, and #81 (all Health Service Workers). Resident #84 did not receive her tray until 6:00 p.m., after the other residents at her table had finished their meal. An interview with Employee #70, a licensed practical nurse, on 10/15/13 at 6:00 p.m., revealed all residents seated at the same table in the dining room should be served and fed at the same time. This employee stated she did not realize Resident #84 had not been served or she would have served and fed her. An interview was conducted with Employee #81, a health services worker, on 10/15/13 at 6:15 p.m. This employee stated All residents are normally served and fed at the same time however today was a little chaotic. d) Resident #91 During an observation on 10/15/13 at 5:50 p.m. in the A dining room, Resident #91 stood up from the table and an alarm started to sound as she started to walk away. The health service worker (Employee #81) was observed to be sitting close by, feeding another resident. She got up and approached this resident and instructed her to sit back down. The resident stated I have to go to the bathroom. Employee #91 replied to the resident that she needed to sit down until someone could help her. The resident then stated I think I am going to have a bowel movement. The health service worker again told the resident that she needed to sit back down until someone could help her. She assisted the resident back to her chair and when she sat her down the alarm stopped sounding. Employee #81 then went back to feeding the other resident and did not ask anyone to assist this resident to the bathroom. Resident #91 was observed in the dining area another ten (10) minutes, until 6:00 p.m., sitting in her chair staring straight ahead. The licensed nurse (Employee # 70) was assisting residents in the dining room and was made aware of this observation. She immediately approached the resident and ask her if she needed to go to the restroom. The resident stated No I do not need to go now. The nurse told the resident she would assist her and the resident again said no. The nurse agreed that the health service worker should not have told this resident to sit back down and not had someone take her to the restroom when she requested. The Director of Nursing (Employee #6) was made aware of this observation on 10/17/13 at 3:00 p.m. She agreed that the health service worker did not respond to this resident's request appropriately. e) Resident #56 During an observation of the middle A wing dining room on 10/15/13 at 6:00 p.m., Resident #56 was observed sitting in a geri-chair. She had completed her meal and was attempting to leave the dining room. She was observed moving her geri-chair with her feet and was partially out the door. At that time, the health service worker (Employee #81) was observed to stop feeding the resident she was assisting in the dining room. She grabbed Resident #56's chair from the back without saying a word to the resident to inform her she was going to move her. She then pulled the resident's chair backwards without speaking to the resident and put her back at the table where she had been sitting. The health service worker did not speak to the resident or tell her what she was doing. The health service worker then resumed feeding the other resident without ever speaking to Resident #56. It was determined that pulling the resident's chair backwards without speaking to her, or telling her what she was doing, and placing her back in the dining room at the table, was not treating the resident with respect and dignity. The Director of Nursing (Employee #6) was made aware of the dining room observations on 10/17/13 at 3:00 p.m. She agreed that not speaking to the resident and telling her what you are going to do prior to pulling her backwards was not treating the resident in a dignified manner. f) Resident #78 During a lunch meal, on 10/16/13, at 11:30 a.m., a health service worker (HSW) was assisting Resident #78 with his meal. Observation from 11:30 a.m. until 11:55 a.m. revealed no evidence of communication between the resident and the staff member. After Resident #78 completed his meal, the HSW assisted another resident, and did not converse with him either.",2017-06-01
7330,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2013-10-22,253,E,0,1,TQVD11,"Based on observation and staff interview, it was determined the facility failed to ensure effective maintenance services. The AC dining room was not in good repair. The ceiling tiles and blinds were covered with a yellow stain and the entrance door was scratched and rusted. This was found for one (1) of six (6) dining rooms observed; however, the practice had the potential to affect more than an isolated number of residents. Facility census: 87. Findings Include: a) Observation of the AC dining room on 10/15/13 at 4:40 p.m. found the ceiling tiles and window blinds were covered with a yellow stain. The entrance door to the AC dining room was rusted and the paint was missing in several areas. An interview with Employee #6, the director of nursing (DON) on 10/22/13 at 11:45 a.m. revealed the AC dining room was used for residents who smoke. The DON stated the appearance of AC dining room was unacceptable and would be redone as soon as money was available. An interview with Employee #82 (Building and Grounds Manager) was conducted on 10/22/13 at 12:00 p.m. Employee #82 stated, he had let the AC dining room slip through the cracks due to money issues.",2017-06-01
7331,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2013-10-22,272,D,0,1,TQVD11,"Based on resident interview, family interview, staff interview, medical record review, and observation, the facility failed to ensure Resident #38's comprehensive assessment accurately reflected the resident's current dental status. The care area assessment (CAA) for Resident #24 did not address the issue of the resident's loose dentures. Two (2) of twenty-two (22) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS) were affected. Resident identifiers: #38 and #24. Facility census: 87. Findings include: a) Resident #38 During an interview with Resident #38 in Stage 1 of the QIS, at 5:07 p.m. on 10/15/13, the resident said her lower front denture was broken. She said it had been broken since she was admitted . Observation of the resident's mouth revealed a missing tooth from the lower front denture. Review of the minimum data set (MDS), with an assessment reference date (ARD) of 08/21/13, noted a dash in the area of the resident's oral/dental status of broken or loosely fitting full or partial dentures (chipped, cracked,. ) During an interview with Employee #110 (nurse assessment coordinator), on 10/01/13 at 1:40 p.m., she related the dash indicated the resident had no broken dentures. She related she was unaware the resident's dentures were still broken, and acknowledged the MDS was incorrect. b) Resident #24 Review of the resident's significant change MDS, with an ARD of 09/04/13, found Section (L) was coded to indicate the resident had broken or loosely fitting full or partial dentures and no natural teeth or tooth fragments. The 09/23/13 CAA, triggered by the information in Section (L) of the MDS for Dental Care, found the following documentation: This residents dental condition triggered due to not having any teeth mouth care is bid (twice a day) and prn (as needed) by staff. Report painful areas in mouth, decreased appetite, refusal of meals. Risk factors include cognitive impairment for oral hygiene, not being able to do her own mouth care, staff anticipate all her wants and needs. Proceed with plan of care. During a family interview, conducted on 10/16/13 at 3:00 p.m., it was identified this resident received new dentures a while back, but the family member was not sure when this occurred. The family member stated when she visited Resident #24, the resident's dentures were never in her mouth. The family member said she was not sure why the resident did not wear them. On 10/21/13 at 3:00 p.m., staff placed the resident's dentures in her mouth at the request of the surveyor. The dentures were too big and did not stay in the resident's mouth. The resident was unable to talk with the dentures in her mouth. The CAA note did not indicate the need for further assessment of the ill filling dentures. Although the MDS identified the dentures were broken and loosely fitting, there was no further assessment to identify if other interventions were needed.",2017-06-01
7332,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2013-10-22,278,D,0,1,TQVD11,"Based on resident interview, family interview, staff interview, medical record review, and observation, the individual completing Section L (Oral/Dental Status) of the Minimum Data Set (MDS) assessment for Resident #38 failed to ensure the assessment accurately reflected the resident's dental status. This was found for one (1) of twenty-two (22) residents reviewed during Stage 2 of the Quality Indicator Survey. Resident identifiers: Facility census: 87. Findings include: a) Resident #38 During an interview with Resident #38 in Stage I of the Quality Indicator Survey, at 5:07 p.m. on 10/15/13, the resident said her lower front denture was broken. She said it had been broken since the time of admission. Observation of the resident's mouth revealed the lower front denture was a missing tooth. Review of the minimum data set (MDS), with an assessment reference date (ARD) of 08/21/13, noted a dash in the area of the area of the resident's oral/dental status of broken or loosely fitting full or partial dentures (chipped, cracked, .) During an interview with Employee #110 (nurse assessment coordinator), on 10/1/13 at 1:40 p.m., she related the dash indicated the resident had no broken dentures. She said she was unaware the resident's dentures were still broken, and acknowledged the MDS was incorrect, however, the MDS had been signed as being accurate.",2017-06-01
7333,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2013-10-22,279,D,0,1,TQVD11,"Based on medical record review, staff interview, resident interview, family interview, and observation, the facility failed to develop a care plan for two (2) of twenty-two (22) residents reviewed during Stage 2 of the Quality Indicator Survey. A care plan was not developed to ensure the safety of a resident (Resident #38) who smoked and had a prior history of unsafe smoking practices. Resident #24 was identified with dental needs, but this issue was not addressed in the resident's care plan. Resident identifiers: #38 and #24. Facility census: 87. Findings include: a) Resident #38 Medical record review on 10/17/13 at 8:00 a.m. found a nursing note, dated 09/23/13 at 1:20 p.m. The note indicated Resident #38 returned to the facility, after a smoke break, with an orangish/black burn mark on her right middle finger. According to the note, the resident informed the nurse she had burned herself with a cigarette. The resident confirmed during an interview, on 10/21/13 at 1:20 p.m., she had burned her finger while smoking. Further review of the medical record revealed a hospital transfer summary, dated 05/13/13. The transfer summary noted the resident was a danger to herself and others because she had burned herself several times and had minor accidents at home with the lighted end of the cigarette. On 10/22/13 at 10:45 a.m., the director of nursing (DON) confirmed she was unable to provide evidence a care plan was developed to address how the facility would ensure safe smoking practices for the resident. b) Resident #24 The current care plan, dated 09/04/13, was reviewed for this resident. This care plan identified that Resident #24 received an altered texture diet related to edentulous. The goal was, She will eat the amount of food she is able to eat at each meal daily over the next three (3) months. An intervention for this goal said, Edentulous/ dental PRN (as needed ) for c/o (complaints) of pain or symptoms. During a family interview, conducted on 10/16/13 at 3:00 p.m., it was identified this resident received new dentures a while back, but the family member was not sure when this occurred. The family member stated when she visited Resident #24, her dentures were never in her mouth. The family member stated she was not sure why the resident did not wear them. During an interview with the unit licensed practical nurse, Employee #2, on 10/21/13 at 3:00 p.m., she verified the resident had not worn her dentures in a long time. Employee #2 was asked if she could place the dentures in the resident's mouth providing the resident did not refuse. Employee #2 was observed to place the dentures in the resident's mouth and the dentures were noticeably loose. The resident was unable to talk due to the dentures slipping out of her mouth. The resident then allowed the nurse to apply adhesive to the dentures. After applying the adhesive, the dentures continued to slip out of the resident's mouth. Employee #2 stated she would make an appointment for a dental consult for the resident. There was no care plan identifying the resident's dentures did not fit and she needed a dental consult.",2017-06-01
7334,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2013-10-22,318,D,0,1,TQVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure a resident, identified as having contractures, received the services specified in his care plan to prevent further decrease in range of motion. This was true for one (1) of two (2) residents who triggered the care area of range of motion in Stage 2 of the Quality Indicator Survey. Resident identifier: #4. Facility census: 87. Findings include: a) Resident #4 The resident was identified during Stage 1 of the Quality Indicator Survey (QIS), at 2:34 p.m. on 10/16/13, as having a contracture of the left hand with no splinting devices. Further review of the care plan, on 10/21/13 at 12:52 p.m., noted a [DIAGNOSES REDACTED]. The goal was to maintain the resident's current range of motion (ROM) with no further contractures. Active/passive ROM was to be provided by nursing staff while providing activities of daily living (ADL) care. Occupational therapy (OT) and physical therapy (PT) referrals were to be made as changes occurred. Resident #4 was to attend special needs classes for grasp and release exercises as recommended. Review of the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 09/05/13, found the resident was coded as having contractures of the left hand, wrist and elbow. No special treatments were noted for therapy or restorative care. An interview with Employee #60, the program manager (PM), on 10/21/13 at 2:11 p.m., revealed the resident was to attend restorative therapy five (5) days a week. Employee #60 stated staff try to bring him to the special needs unit, but if not, staff will work with him on the unit. She added the resident will swat them away if he does not want to attend. According to this employee, Employee #64, a health service assistant, usually worked with this resident. Employee #60 provided a log indicating the special needs unit worked on grasp and release. The log indicated he used only his right hand. Notes for October 2013 were reviewed. The notes indicated the resident participated on 10/01/13, 10/03/13, 10/04/13, 10/07/13, 10/08/13, 10/09/13, 10/10/13, 10/15/13, 10/16/13, 10/17/13, and 10/21/13. He was noted as sleeping on 10/11/13 and 10/18/13. The staff member was not working on 10/14/13. Activities included: placing blocks in an open can, tossing a ball, stacking cones, put rings on a stacking base, using a round jumbo peg board, and placing blocks in an open canister. It was noted he completed tasks with his right hand. A dash was noted for his left hand. An interview with a health service worker (HSW), Employee #155, on 10/21/13 at 2:33 p.m., revealed nursing staff did not provide interventions related to Resident #4's left hand contracture. She said that restorative worked with him. The HSW said she only worked with the resident occasionally, but was not aware of any intervention by nursing staff. Another interview, with a health service worker (Employee #129), on 10/21/13 at 2:37 p.m., revealed she was unaware of any interventions related to the left hand contracture. She too, said restorative worked with the resident. Employee #27, a licensed practical nurse (LPN) was interviewed on 10/22/13 at 8:35 a.m. She said Resident #4 did not use his left hand. She said restorative therapy was responsible for range of motion services. The health service assistant, Employee #64, was interviewed on 10/21/13. When asked about range of motion services, she said range of motion was only completed with the right had. She said the resident had ticks, and some days he would grab the thumb of his left hand and just shake it. The care plan was reviewed with the director of nurses on 10/22/13. She acknowledged the care plan was not being implemented as indicated for range of motion services for the left hand. She agreed the interventions were being used to provide range of motion to the right hand only. She indicated the resident was noncompliant with care, but she was unable to provide evidence range of motion had been attempted with the resident's left hand.",2017-06-01
7335,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2013-10-22,323,D,0,1,TQVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, policy review, and medical record review, the facility failed to identify and evaluate risks for one (1) of (2) residents reviewed for the care area of accidents. The facility was aware the resident had a prior history of unsafe smoking habits and failed to follow their policy to complete a smoking assessment to identify and prevent future incidents / accidents. Resident identifier: #38. Facility census: 87. Findings include: a) Resident #38 Medical record review, on 10/17/13 at 8:00 a.m., found a nursing note dated 09/23/13 at 1:20 p.m. which indicated when Resident #38 returned to the facility, she had an orangish/black burn mark on her right middle finger. According to the note, the resident informed the nurse she had burned herself with a cigarette. Further review of the medical record revealed a hospital transfer note, dated 05/13/13, which noted the resident was a danger to herself and others because she had burned herself several times and had minor accidents at home with the lighted end of a cigarette. The resident confirmed, during an interview on 10/21/13 at 12:39 p.m., she had burned her finger while outside the facility, and was treated for [REDACTED]. She said, The nurse treated it with burn cream. Employee #179, a licensed practical nurse (LPN) was interviewed on 10/21/13 at 12:50 p.m. She related registered nurses (RN) completed smoking evaluations. She said she was not aware of a burn, but had noted brown nicotine stains on the resident's fingers. Further review of the medical record found no evidence a smoking assessment had been completed. Review of the facility's safe smoking policy assessment policy revealed an assessment was to completed within seven (7) days of admission and annually. The assessment was to be reviewed on the next conference date. During an interview with the director of nursing (DON), on 10/17/13 at 3:00 p.m., she said she would look for a smoking safety assessment. On 10/22/13 at 10:45 a.m., the DON confirmed she was unable to provide evidence a smoking evaluation had been completed between admission and 10/17/13. She said one should have been completed on admission, but had not been completed until 10/18/13, after the inquiry was made.",2017-06-01
7336,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2013-10-22,333,D,0,1,TQVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and observation, the facility failed to ensure residents were free from significant medication errors. A resident who had been recently readmitted was given twice the ordered dose of [MEDICATION NAME]. One (1) of four (4) residents observed during the observation of medication administration was affected. There were twenty-five (25) opportunities for error. Resident identifier: #43. Facility census: 87. Findings include: a) Resident #43 During medication administration pass observation with Employee #27, a Licensed Practiced Nurse (LPN), she was observed giving medications to Resident #43. During the process, she stated she was giving the resident [MEDICATION NAME] 200 mg (milligrams) po (by mouth). She then removed [MEDICATION NAME] 200 mg from the medication cart. Upon reconciliation of the observed medication pass with the physicians' orders following the medication administration pass, it was found the order was actually for [MEDICATION NAME] 100 mg po. The Medication Administration Record [REDACTED]. On 10/23/13 at 10:30 a.m., this was discussed with the Director of Nursing who agreed it was a significant medication error. She immediately had a [MEDICATION NAME] level ordered for the resident. The medication cart was checked at 10:45 a.m. on 10/23/13. It contained both 100 mg and 200 mg packages of [MEDICATION NAME] for this resident. The nurse removed the 200 mg dose at that time to prevent future error.",2017-06-01
7337,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2013-10-22,371,F,0,1,TQVD11,"Based on staff interview and observations, it was determined the dietary staff did not maintain foods under sanitary conditions. The equipment needed to dispose of used paper towels was not available and there was no internal thermometer in the ice cream freezer to ensure the items were being kept at the proper temperature. This had the potential to affect all residents who consumed foods by oral meals as all foods were prepared and served from this central location. Census: 87. Findings include: a) During the initial tour of the dietary department on 10/15/13 at 1:30 p.m., with Employee #55, nutritionist, the following issues were observed: 1. The hand sink in the kitchen area near the food preparation area did not have a trash can with a step-on device to raise the lid. This was needed prevent the potential for contamination of the employees' hands should they use their clean hands to lift the lid off of a regular type trash receptacle. 2. A chest type freezer, in which ice cream cartons were kept, had no internal thermometer which would enable staff to determine if items were being maintained at the appropriate temperature. This was confirmed with Employee #55 who was present during the tour.",2017-06-01
7338,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2013-10-22,412,D,0,1,TQVD11,"Based on observation, staff interview, and record review, the facility failed to obtain dental services for a resident when her dentures did not fit properly. Resident #24's dentures were too large and this had not been addressed by the facility to ensure the resident's dental needs were met. This was true for one (1) of three (3) residents who were reviewed in Stage 2 for the dental care area. Resident identifier: #24 . Facility Census: 87. Findings include: a) Resident #24 During an observation on 10/21/21 at 3:00 p.m., Resident #24 was observed without her dentures. When Employee #2, a nurse, was questioned, the nurse obtained the dentures and placed them in the resident's mouth. The dentures were too big and were moving up and down in the resident's mouth. The resident was unable to make herself understood when speaking due to the loose dentures. The nurse removed the dentures and applied dental adhesive to the dentures, which did not help. The dentures continued to move up and down and eventually fell out of the resident's mouth. Employee #2 stated the resident had a past consult and the dentures had been repaired. This employee reviewed the medical record and verified the dentures were repaired on 09/28/10 (more than three (3) years prior to this date). The nurse verified there was no evidence the resident had any dental consults after 09/28/10. After identification of this issue during the survey, a dental consult was made on 10/21/13 for the resident's loose fitting dentures.",2017-06-01
7339,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2013-10-22,441,E,0,1,TQVD11,"Based on observation and staff interview, the facility failed to reduce the potential for the spread of infection and cross contamination. Residents were not provided an opportunity to wash their hands prior to eating their meals. This was identified for all dining areas and had the potential to affect all residents requiring assistance with hand washing. Facility Census: #87. Findings include: a) Hand washing During an observation of the facility dining rooms on 10/15/13, beginning at 4:15 p.m., the residents were observed to arrive in the dining areas for dinner. Some residents were brought in by staff, some walked in, and others wheeled themselves in to the rooms. Many of the residents had been in the halls for an extended period of time prior to going to the dining room and did not have access to a sink to wash their hands prior to going to meals. Some of the residents who wheeled themselves into the dining room, had used their hands to propel their wheelchairs and needed to be afforded the opportunity to clean their hands before eating. It was observed that staff cleaned their own hands with hand sanitizer, but did not provide residents with an opportunity to clean their hands before the dinner meal was served. A second meal observation was of the noon meal on 10/17/13. Again it was noted residents were not provided an opportunity to clean their hands prior to the meal service. During an interview with a licensed nurse (Employee #1), on 10/22/13 at 11:35 a.m., she confirmed staff should have used hand sanitizer to clean the resident's hands prior to meals. She stated since this had been brought to the facility's attention, they will make sure this is done.",2017-06-01
8737,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2012-08-17,166,D,0,1,4EJV11,"Based on resident interview, staff interview, review of facility policy and procedure investigations of complaints/allegations, and medical record review, the facility failed to safeguard the resident's personal property by failing to investigate and seek a resolution when it was discovered the resident's dentures were missing. This was true for one (1) of two (2) residents reviewed for the care area of personal property in Stage II of the quality indicator survey. Resident identifier: #54. Facility census: 95. Findings include: a) Resident #54 During an interview with the resident, on 08/13/12, the resident reported her upper and lower dentures were missing. The resident was unsure how long the dentures had been missing. The resident further stated she needed her dentures and she had told, the girls, her dentures were missing. Review of the medical record found a dental consult had been scheduled for the resident on 07/20/12. An interview with the director of nursing (DON), at 12:20 p.m. on 08/15/12, revealed the resident had not been sent for the dental consult on 07/20/12 as scheduled because the resident's dentures were missing. The director of nursing stated the 07/20/12 appointment was initially scheduled because the resident's dentures were not fitting properly. On 08/16/12 at 3:30 p.m., the DON verified the facility had not initiated a search for the dentures and had not attempted to provide a resolution when it was determined the resident's dentures were missing. She verified a suggestion and complaint form should have been completed when it was discovered the dentures were missing. Review of the facility's policy entitled, Complaint/Allegation Investigation, found: .B. Complaints, Allegations of Abuse, Neglect or other Violations of Resident Rights: Allegations made under this policy may be filed in relation to any aspect of a resident's treatment, housing, services, accommodations, etc. F. Investigation: 1. The Resident Advocate will immediately begin to gather facts, conduct interviews, and review medical records as necessary to determine the circumstances surrounding the allegation (s)",2016-04-01
8738,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2012-08-17,225,D,0,1,4EJV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Suggestion and Complaint Forms, Abuse / Neglect Reporting Requirements for West Virginia Nursing Homes and Nursing Facilities (Revised October 2011), and staff interview, the facility failed to report an allegation of physical abuse to the proper state agencies as required. This was true for one (1) of thirty (30) suggestion and complaint forms reviewed. Resident identifier: #67. Facility census: 95. Findings include: a) Resident #67 Review of the facility's, Suggestion & Complaint Form, found a complaint, dated 01/03/12, in regards to Resident #67. The form included Attempting to give (name of resident) a [MEDICATION NAME] injection. Held him down to give [MEDICATION NAME] shot. He got a skin tear on elbow and knuckle-right arm. Upper left arm was squeezed. Watchband broken. The allegation was signed by the resident. Further review of the complaint form found the facility's response to the corrective action taken was documented as: None, resident said not their fault it was my fault. I resisted them. Will order you a new watch band. The director of nursing was interviewed, at 5:00 p.m. on 08/14/12, and was unable to provide any evidence the allegation of abuse was reported to the appropriate State agencies as required by law. According to the Reporting Guidelines for West Virginia Nursing Homes and Nursing Facilities, abuse is defined as, The infliction or threat to inflict physical pain or injury on or the imprisonment of any incapacitated adult or facility resident. The guidelines further require reporting of allegations of abuse to Adult Protective Services, the Ombudsman, and Office of Health Facility Licensure and Certification (OHFLAC).",2016-04-01
8739,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2012-08-17,241,E,0,1,4EJV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interviews/comments, medical record review, and staff interview/comments, the facility failed to maintain dignity for residents during the service of the evening meal on 08/13/12. This affected ten (10) of ninety-five (95) residents whose meal service was observed. Resident identifiers: #85, #96, #21, #90, #54, #59, #101, #5, #64, and #48. The facility also failed to ensure residents were treated with dignity and respect when interacting/conversing with residents. This was true for two (2) randomly observed residents. Resident identifiers: #88 and #23. Facility census: 95. Findings include: a) Observations of B/D dining room The B/D dining room evening meal service was observed from 5:10 p.m. through 6:10 p.m. on 08/13/12. The facility staff failed to serve all residents who were seated together at a table at the same time. 1) Resident #21 was seated at the first table with Resident #90. Resident #21 received a tray, then staff proceeded to serve Resident #75 seated at a second table with Resident #96. Residents #35, #59, and #101 were seated at a third table. Only Resident #35 received a tray. Staff then served Resident #85 who was seated at a fourth table. 2) Resident #54 This resident received a tray at 5:15 p.m. on 08/13/12. The resident looked at the food items on her tray and stated, I don't want this, I want pizza, I ordered pizza. (Pizza was the substitute for the evening meal). Employee #140 responded, It's not on your diet, and failed to offer choices of any other food items. The resident continued to state over and over, I don't want this, get this out of here, I want pizza. At 5:30 p.m., another staff member told the resident she would have someone from the kitchen come and talk with her. At 5:35 p.m., the dietary manager told the resident she could have a grilled cheese sandwich and soup, which the resident agreed to eat. Several minutes after the dietary manager left the dining room, the Resident began yelling, Where is my food? At 6:05 p.m. on 08/13/12, a licensed practical nurse, Employee #27, entered the dining room and stated, I don't know where her soup and sandwich are,but I'm going to the kitchen to get it myself. At 6:10 p.m., the resident received her soup and a sandwich. By this time, all the other residents in the dining room had finished eating their meal and were exiting the dining room. 3) Resident #21 This resident received a tray, at 5:10 p.m. on 08/13/12, from Employee #53, a health services worker. The resident was seated in a reclining geri-chair horizontally placed at the table. Employee #53 did not speak to the resident or set up his tray. The lids remained on the beverages and the dome cover remained on his plate. The resident was unable to reach any of the food items on his tray. At 5:30 p.m. the surveyor asked Employee #53 if she was going to set up the Resident's tray. She replied, He's a feed. At 6:00 p.m., Employee #53 asked the resident if he wanted to eat and he replied, No. She then removed the tray without attempting to encourage the resident to eat or even telling the resident what food items were on his tray. 4) Resident #85 Resident #85 was observed trying to leave the dining room at 5:45 p.m. Employee #53 told the Resident, You can't leave here, we are all in here, there's nobody out there. Employee #53 then pushed the resident's wheelchair back to his table. b) These issues that were observed in the dining room were discussed with Employee #27 at 6:10 p.m. on 08/13/12. The director of nursing was also advised of the observations made in the B/D dining room at 6:20 p.m. on 08/13/12. c) A/C Inner Dining Observation During an observation of the dinner meal, on 08/13/12 at 5:30 p.m., it was determined this meal was not a pleasant and dignified dining experience. 1) Residents #5, #64, and #48 were observed to be sitting at the same table in the A/C inner dining area. There was a white substance spilled on the table (milky appearance) and was running all over their table. The liquid was soaked into the place mats on the table. The residents ate the entire meal without intervention from staff to clean up the spilled milky substance. 2) There were three (3) flies observed at Residents #5, #64, and #48's table the entire meal from 5:30 p.m. to 6:30 p.m. These flies kept landing on each resident's food and never left the table the entire meal. 3) Resident #48 This resident was observed to be eating with a large handled spoon and did not have a fork. She had a piece of pizza, a bowel of pears, and a garden salad. She was observed to try to eat her pizza and was having difficulty. On two (2) different occasions she was heard yelling out help and the staff members working in the dining area would say what do you need, but they never went to her table to see whether she needed help and she did not answer them. She ask the surveyor will you help me cut this up. The staff members did not treat this resident with dignity when she requested assistance and ignored her repeated requests for help. Resident #48 was observed for the entire meal and she did finally eat a piece of pizza with much difficulty. She tried to eat her pears, but they kept falling off of the spoon. It was determined this resident's dinner experience was unpleasant as the table at which she sat had spills soaking through her place mat, flies were landing on her food continuously throughout the entire meal, staff ignored her requests for help, and she was trying to eat her food with only a spoon. The Dietary Supervisor (Employee #55) was questioned at 5:45 p.m. on 08/13/12 about Resident #48's eating utensils. When asked if there was a reason she did not have a fork, he stated the large handled spoon was all that was on her tray card and was all they sent. He also observed the flies and the spilled milk on the table. 4) The A/C Inner Dining Area was observed and there were five (5) staff members assisting residents in that area for dinner on 08/13/12. The staff members did not talk to the residents while they were feeding them. There were no conversation between staff and residents to make this a pleasant dining experience. d) Resident #88 Review of the medical record revealed a nursing entry, dated 08/12/12 at 21:33, that included stated that the resident was making too much noise behind her and that she shouldn't have to listen to that. It was then recorded the HSW (health service worker) redirected her by saying that the dining room was for all the residents and everyone had as much right to be in there as she did. The resident finished her lunch with no more complaints about her fell ow residents. The assistant director of nursing (ADON), Employee #4, was made aware of this entry and agreed that this was not treating the resident with dignity and it would have been better to just move the resident. During an interview with this resident, on 08/16/12 at 2:00 p.m., the resident stated she wore earplugs all of the time because noise bothered her. She said she had a [MEDICAL CONDITION] and it caused the noises to bother her. e) Resident #23 During an observation, on 08/16/12 at 4:30 p.m., this surveyor was sitting at the nurses' station by the D wing. Employee #82 was observed to be halfway down the D hall administering medications. Resident #23 said she had to go to the bathroom again. Employee #82 was heard saying you have went to the bathroom a lot maybe you have a UTI (urinary tract infection) how many times have you peed today? This statement was overheard by the surveyor sitting at the nurses' station and there were five (5) residents sitting in the hall that could hear the statement made by the nurse. Employee #4 was made aware of the nurse's comment to the resident, at 4:45 p.m. on 08/16/12. She confirmed this was not treating the resident in a dignified manner.",2016-04-01
8740,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2012-08-17,242,D,0,1,4EJV11,"Based on record review and staff interview, the facility failed to honor the request of a resident to have a male provide assistance with bathing. This affected one (1) of four (4) residents who triggered for choices during Stage I of the survey process. Resident identifier: Resident #69. Facility Census: 95. Findings include: a) Resident #69 On 08/14/12 at 1:00 p.m., a review of the social history summary sheet, dated 03/07/12, found a statement, He (Resident #69) prefers a shower and he is a VERY private person and needs to have a male staff help him with his shower. This was noted by the social worker (Employee #152). A review of the care plan, on 08/14/12 at 2:00 p.m., revealed the care plan had been reviewed on 05/29/12. Interventions included, Cue resident regarding personal hygiene as needed and assist only to the extent needed. Encourage independence. Baths per facility schedule - . prefers a shower. He requires oversight assistance with bathing. Respect his request for privacy. No interventions were found regarding Resident #69's request for a male to assist with a shower. In an interview, with the director of nursing, on 08/15/12 at 3:15 p.m., she agreed the care plan did not contain interventions regarding Resident 69's request for a male to assist with bathing. She further stated, the facility only had two male nursing assistants. On 08/17/12 at 8:30 a.m., an interview with a licensed practical nurse (Employee #9) revealed Resident #69 takes most of his bath by himself. She stated when he needs help whoever, male or female, will help him.",2016-04-01
8741,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2012-08-17,272,D,0,1,4EJV11,"Based on record review and staff interview, the facility failed to identify the presence of a pressure ulcer on the Minimum Data Set (MDS) assessment. The skin condition for Resident #91 was not accurately coded to reflect his condition at the time of the assessment. This was found for one (1) of twenty-five (25) residents whose MDS assessments were reviewed for the Stage II sample. Resident identifier: #91. Facility census: 95. Findings Include: a) Resident #91 A nursing progress note, dated 06/01/12, revealed this resident had impaired skin integrity r/t (related to) incontinence and frequent friction when sitting in chair as resident slides and repositions himself frequently. Stage 3 (three) pressure ulcer to lt inner buttock and stage 2 (two) pressure ulcer to the right inner buttock superficial layer of tissue is peeling. Current measurements: lt (left) buttock wound 1.5 cml (cm long) x 1.4 cmw (cm wide) x 0.1 cmd (cm deep) rt (right) buttock wound 0.5 cml x 0.5 cmw x 0 cmd. The treatment records, for June 2012 and July 2012, contained an entry that instructed cleanse the open area to coccyx with wound cleaner and apply allevyn dressing. The instructions stated to change this dressing every three (3) days. The treatment record indicated that this had been checked and confirmed that this area was present at the time of the MDS completed on 07/01/12. A significant change in status MDS, with an assessment reference date (ARD) of 07/01/12, revealed no problem with this resident's skin condition. Section M0210 asked does the resident have one or more unhealed pressure ulcers at Stage 1 (one) or higher. This section was coded 0. This coding meant that no pressure areas were present. During an interview with the MDS nurse (Employee #14) the morning of 08/16/12, she stated It should be in section M, but it isn't there .",2016-04-01
8742,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2012-08-17,280,D,0,1,4EJV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure care plans were revised to reflect the current treatment needs of residents. The care plan for Resident #59 was not updated when there were changes to her [MEDICAL TREATMENT] treatment plan; Resident #88's care plan did not reflect the resident's skin condition; and the care plans for Residents #21 and #62 were not revised to reflect the changes in their nutritional needs. The care plans were not revised and updated for four (4) of twenty-five (25) sampled Stage II residents. Resident identifiers: #59, #88, #21, and #62. Facility Census: 95. Findings Include: a) Resident #59 A review of the medical record revealed this resident had a care plan that was last reviewed 07/03/12. The plan reflected she was receiving [MEDICAL TREATMENT] three (3) times a week. The interventions stated the facility was to send the resident's blood pressure medications with resident to the [MEDICAL TREATMENT] center on [MEDICAL TREATMENT] days. On those days, the medications were not to be given at the facility. During an interview with the nurse (Employee #78), on 08/16/12 at 10:25 a.m., she verified the facility did not do this anymore because the [MEDICAL TREATMENT] center said they do not need them to send her medication because her blood pressure was never up and they did not have to give the medication. Employee #4 (assistant director of nursing) was made aware that according to the nurse, they did not send the medications to [MEDICAL TREATMENT] anymore as instructed in the care plan. She verified the care plan interventions had not been updated to reflect this. b) Resident #88 The care plan for this resident was last updated 06/22/12. The problem High risk for skin breakdown and the goal residents skin will remain intact and she will have no breakdown by next review was reviewed and continued at that time. Review of the medical record revealed that she had skin irritation to her buttocks and inner thighs and she was not to wear briefs at HS (hours of sleep). The medical record also confirmed, that on 06/15/12, the resident had a blister present on her inner thigh. It was verified this was present when her care plan was updated on 06/22/12, but her care plan was not revised to reflect that she had and actual skin condition problems at that time. Employee # 4 confirmed that this skin condition was present at the time of the care conference on 06/22/12. She also confirmed that the resident developed further skin breakdown on 06/29/12. This area was treated and measures were implemented, but the plan of care was not updated to reflect the true skin condition. c) Resident #21 Review of the medical record found the resident had experienced a decline in activities of daily living, increased confusion, lethargy and falls related to a [MEDICAL CONDITION]. The resident began receiving hospice services on 07/17/12. Review of the hospice care plan found the problem, Nutrition. The goal associated with this problem was: Patient/caregiver will verbalize understanding of changes in appetite related to advancing disease process, and / or impending death. The interventions were: Educate / review on nutrition as related to the normal process of dying and eating for pleasure as desired. Further review of the facility's care plan, dated 07/12/12, found a problem: weight: low weight (113#) and BMI (17.7). The goal associated with this problem was: Resident will lose or gain weight until within IBW (ideal body weight) range 133-163. Review of the resident's weights found the last recorded weight was 115.2 pounds on 07/25/12. Review of the daily percentage of meal consumption for August 1, 2012 through August 15, 2012 found the resident refused 30 of 42 meals recorded on the meal consumption sheet. On 08/16/12 at 10:45 a.m., an interview was conducted with Employee #55, the nutritionist, and Employee #14, a registered nurse, regarding the care plan. Employee #55 stated the care plan was not updated after the resident began receiving hospice services and stated the resident was not refusing meals when the care plan was written on 07/12/12. d) Resident #62 Review of the medical record found a consult from the registered dietitian, completed on 05/28/12. The consult included, Weight history indicates a sign.(significant) weight loss x 30 days. Unsure of reason for such a weight loss x 1 month, however please note res. (resident) is now back at weight x 6 months ago. It should be noted Res. weights fluctuate greatly from 172 - 203 # (pounds). res. (resident) should continue to be monitored for fluid gains/losses. Believe current plan remains appropriate. If weight loss continues at sign rate may need to consider nutritional supplement. Review of the resident's current dietary care plan, dated 06/26/12, revealed a problem: Receiving a therapeutic diet. The goal associated with this problem was: (name of resident) blood glucose level will be maintained WNL (within normal limits) daily. Will maintain adequate nutritional status as evidenced by lab values of DM-2 (diabetes mellitus, type 2) [MEDICAL CONDITION](hypertension) status for next three month period. The care plan failed to address the resident's current weight loss, fluctuating weights and how the facility planned to evaluate/determine the underlying reasons for the resident's weight loss. During an interview with the DON (director of nursing) and the dietary manager, at 5:30 p.m. on 08/15/12, the DON stated the physician had evaluated the resident's weight loss and had taken steps to determine the reasons for the weight loss. She agreed the interventions the facility had taken to address and evaluate the resident's fluctuating weight loss, such as scheduling an appointment with a [MEDICATION NAME], had not been added to the care plan.",2016-04-01
8743,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2012-08-17,282,D,0,1,4EJV11,"Based on record review and staff interview, the facility failed to ensure that a nutritional consult was completed in a timely manner. This nutritional consult was request on 07/17/12 due to the resident's weight loss. During the medical record review, no evidence could be found to show the nutritional consult had been completed as of 08/14/12. This practice affected one (1) of four (4) residents reviewed for nutrition during Stage II of the survey. Resident identifier: #74. Facility census: 95. Findings Include: a) Resident #74 Review of the resident's medical record noted Resident #74's weight on 03/01/12 was 113 pounds. On 07/17/12, the resident's weight was recorded as 101 pounds. A nutritional consult request sheet had been completed on 07/17/12. The reason for this request stated please evaluate for wt (weight) loss. On 08/14/12, there was no evidence found in the medical record to verify this consult had been completed. On 08/15/12 at 9:30 a.m., the Assistant Director of Nursing, Employee #4, was made aware there was no evidence of the nutritional consult having been completed. She returned with a consultation note with an entry date of 08/15/12 at 10:45 a.m. This entry date was after the surveyor's finding.",2016-04-01
8744,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2012-08-17,329,D,0,1,4EJV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and a review of the nursing drug handbook, the facility failed to ensure Resident #81 did not receive unnecessary medications. The resident was receiving the medication Levothyroxin ([MEDICATION NAME]) and the resident did not have a [DIAGNOSES REDACTED]. This was true for one (1) of seven 7 sampled residents. Resident identifier: #81. Facility Census: 95. Findings include: a) Resident #81 During a review of the medical record, completed on 08/15/2012 at 4:47 p.m., it was found Resident # 81 was receiving the medication [MEDICATION NAME] ([MEDICATION NAME]) 75 mcg (micrograms) every morning. Further review of the medical record found no [DIAGNOSES REDACTED]. It was further identified there was no laboratory data in the medical record to monitor the use of this medication after 12/31/10. In an interview with Employee #9 (Licensed Practical Nurse), on 08/16/12 at 9:25 a.m., she reported giving this medication to the resident for over a year and was unsure why the resident was taking this medication. A review, on 08/16/12 at 9:47 a.m., of the nursing drug handbook, PharMerica 2012 found a list of the specific conditions for which this medication was prescribed. There was no evidence in the medical record indicating this resident had any of those conditions.",2016-04-01
8745,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2012-08-17,364,D,0,1,4EJV11,"Based on observation and staff interview, the facility failed to serve pureed food in an attractive and appealing manner. When the food items were plated, they flowed together on the plate. This had the potential to affect 45 residents who were ordered pureed foods. Facility census: 95. Findings include: a) On 08/15/12 at 12:00 p.m., observation of the lunch meal, in the C-1 Day Room, revealed the pureed meat, vegetables, and rice had the appearance of flattened patties which were all blending together. The nutritionist was present during this observation. He agreed the food did not look appealing and were not of the appropriate consistency to prevent the blending of foods.",2016-04-01
8746,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2012-08-17,366,D,0,1,4EJV11,"Based on observation, resident interview, and staff interview, the facility failed to ensure residents were offered substitutes when they refused to eat the items on the menu that were served to them. Two (2) residents were served a dinner tray and did not eat any of the served items. The staff did not offer them a substitute of any kind for that meal. This was observed for two (2) of ninety-five (95) residents observed at the dinner meal. Resident identifiers: #64 and #21. Facility Census: 95. Findings include: a) Resident #64 During an observation, on 8/13/12 at 5:10 p.m., Resident #64 was observed in the dining area and was served a pureed meal. She sat and stared at the food, but did not take a bite of food the entire time she was observed. This table was observed from 5:10 p.m. to 5:55 p.m. This resident was asked on two (2) different occasions why she was not eating. She replied I did not want this. The resident did not eat any of her food during that time and there were no staff members observed to come to assist her or to try to encourage her to eat. She was not offered an alternate meal when she did not eat any of the food served to her. The resident was observed to leave the table at 5:55 p.m. and she still had not eaten any of the food she was served. She still had not been offered assistance or an alternative meal. The Director of Nursing was made aware of this observation on 8/14/12 at 2:00 p.m. She was also made aware that it had been recorded in the medical record that this resident ate 100% of her meal when she had been observed to eat nothing that was on her tray on 08/13/12 for dinner. b) Resident #21 Employee #53, a health service worker, was observed to serve this resident his tray at 5:10 p.m. on 08/13/12. At 6:00 p.m., Employee #53 asked the resident if he wanted to eat. The resident replied, No. The employee picked up the resident's tray without any further conversation. The resident was never informed of what the food items were on his tray and was never offered or given the opportunity to receive any substitutes.",2016-04-01
8747,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2012-08-17,428,D,0,1,4EJV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, a review of the nursing drug handbook, and the pharmacist ' s monthly drug regimen reports, the pharmacist failed to identify irregularities in a resident ' s drug regimen. Resident #81 was receiving the medication Levothyroxine (Synthroid) with no [DIAGNOSES REDACTED]. Additionally, there was no evidence laboratory data had been collected in order to monitor the use of this medication. This was true for one (1) seven (7) sampled residents. Resident identifier: #81. Facility Census: 95. Findings include: a) Resident #81 A review of the medical record, on 08/14/12 at 4:47 p.m., found Resident #81 had the following Diagnosis: [REDACTED]. Further review of the medical record identified that Resident # 81 was receiving the medication Levothyroxine (Synthroid) 75 micrograms every morning. There was no [DIAGNOSES REDACTED]. It was further identified there was no laboratory data in the medical record to monitor the use of this medication since 12/31/10. On 08/16/12 at 9:50 a.m., Employee #132 (Registered Nurse), after reviewing the pharmacy monthly drug regimen reports and the laboratory reports, verified there was no [DIAGNOSES REDACTED]. A review of the nursing drug handbook, PharMerica 2012 found the conditions for which this medication was used. This medication reference book also indicated the medication should be monitored every six (6) to eight (8) weeks until normalized; eight (8) to twelve (12) weeks after a dosage change; and every six (6) to twelve (12) months throughout therapy. A review of the monthly drug regimen reviews revealed the pharmacist had not identified a need for a [DIAGNOSES REDACTED].",2016-04-01
8748,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2012-08-17,441,E,0,1,4EJV11,"Based on observation and staff interview, the facility failed to ensure staff employed appropriate infection control practices to help prevent the development and transmission of diseases and infection. A staff member was observed to use the same hair brush on three (3) different residents, employees were observed to not wash their hands when indicated and/or to perform handwashing incorrectly. These practices had the potential to affect more than an isolated number of residents. Resident identifiers: #5, #48, #76, and residents who were assisted after staff did not wash their hands. Facility Census: 95. Findings include: a) Residents #5, #48, and #76 During an observation, on 08/16/12 at 3:30 p.m., Employee #144, a health service trainee, was observed on the A-East unit with a hair brush. She was observed to brush Resident #5's hair, then Resident #48's hair, then she went to Resident #76 and brushed her hair. This was done using the same hair brush for each of these residents. Employee #144 was immediately questioned about this practice 08/15/12 at 3:40 p.m She stated that everyone has their own hairbrush and she was not supposed to use the same brush for the residents. b) Handwashing Observation during the dinner meal. on 08/13/12 at 4:55 p.m., found a licensed practical nurse (Employee #27) washed her hands and dried her hands with paper towels. After turning off the water faucet with the paper towels, she finished drying her hands with the same contaminated paper towels. She then proceeded to serve residents drinks, silverware, and the lunch meal. c) Clothing Protectors During an observation of the A/C inner Dining room, on 08/13/12 at 5:35 p.m., a health service worker (HSW), Employee #79, was observed cleaning a large amount of liquid from the floor with a soiled resident clothing protector. She continued assisting residents in the dining room and did not wash her hands. It was observed that this HSW did not completely clean the liquid off of the floor. The Licensed Practical Nurse (LPN), Employee #94 was observed at 5:38 p.m. (three minutes following the first observation), cleaning the remainder of the liquid from the floor with another soiled resident clothing protector. This employee was then observed to continue assisting the residents in the dining room without washing her hands. On 08/16/12 at 3:00 p.m., the director of nursing (Employee #5) was asked whether it was an acceptable practice to clean spills off of the floor using clothing protectors the residents used at meal times. She stated No.",2016-04-01
8749,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2012-08-17,469,F,0,1,4EJV11,"Based on observation, review of the facility's pest control program, and staff interview, the facility failed to maintain an effective pest control program as evidenced by flies being observed in the kitchen, resident rooms and resident dining areas during the entire survey and by all members of the survey team. Facility census: 95. Findings include: a) Kitchen observation - During the initial kitchen tour, on 08/13/12 at 1:30 p.m., flies were observed in all areas of the kitchen. Additional observations made on 08/14/12, and 08/15/12 at 12:00 p.m., found flies were again in the kitchen. The nutritionist was present during these tours and agreed there were flies in the kitchen. b) Environmental tour - During the initial tour of the facility, on 08/13/12 at 1:30 p.m., flies were reported in resident rooms, hallways, and day rooms by all survey team members. At each daily survey team meeting, the flies remained an issue. Observations made by other survey team members included a nurse giving medications and waving her hands to get flies away from the medication cart; flies flying around residents' heads while they were in bed; two (2) flies flying around a resident's head during a meal in the C-1 dining room; and flies in the day rooms during meals. The nutritionist was present when the observation was made in the C-1 dining room and agreed with the observation. - On 08/17/12 at 9:15 a.m., an interview was conducted with the director of maintenance. He stated no problems had been reported to him regarding the flies. He further stated, the facility is in the middle of a farm area and the flies have been bad. - A review of the pest control program found the facility had been sprayed for ants on 07/25/12, with no mention of flies. c) Dining Room Observation During an observation of the dinner meal, on 08/13/12 at 5:30 p.m., in the A/C inner dining area, Residents #5, #64, and #48 were observed to be sitting at the same table. There were three (3) flies observed at this table throughout the entire meal. These flies kept landing on each residents' food and never left the table the entire meal. There was no intervention by the staff in an attempt to alleviate these pests from the residents' dining table the entire meal.",2016-04-01
8750,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2012-08-17,492,D,0,1,4EJV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the personnel records, staff interview, The West Virginia Criteria Manual (State Standard), and Federal Regulation 42 CFR 75(7), the facility failed to ensure a nursing assistant was registered with the long-term care nursing assistant program as required. This was true for one (1) of two (2) nursing assistant personnel records reviewed. Employee identifier: #113. Findings include: a) Employee #113 Personnel record review, on [DATE] at 1:00 p.m., revealed a Nursing Assistant Registry search result, dated [DATE] for Employee #113 (Health Service Worker). The expiration date for this individual's registration was [DATE]. Information from state registry provided different information. The document was verified by Employee #139 (Administrative Service Manager1, Human Resources) on [DATE] at 1:15 p.m. Reapplication for registration was made by Employee #113 on [DATE]. Employee #113 had worked from [DATE] until [DATE] on expired credentials. The facility had just sent Employee #113 home the day before ([DATE]) due to expired registration. The nursing assistant registry search results, dated [DATE], showed Employee #113 had an original date of registration on [DATE]. The individual's registration had expired on [DATE]. Employee #4 (Nurse IV, Assistant Director Of Nursing) verified this document when presented on [DATE] at 1:30 p.m. She stated they check registrations monthly. In an interview with Employee #5 (Nurse Director I), on [DATE] at 8:50 a.m. Employee #5, it was verified Employee #113 (HSW) had worked from [DATE] until [DATE] with a lapsed registration. When asked if Employee #113 acknowledged expired registration, Employee #5 stated that Employee #113 assumed with re-registration in Ohio that West Virginia registration would also be renewed. The office secretary normally checked monthly for upcoming renewals, somehow he had slipped through.",2016-04-01
8751,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2012-08-17,514,D,0,1,4EJV11,"Based on observations, record review, and staff interview, the facility failed to ensure medical records were completed with accurate information to reflect the status of the residents. Resident #64 had her meal intake recorded inaccurately. Resident #62 had a dental assessment by nursing that was not accurate and did not reflect the true status of the resident. This was true for two (2) of twenty-five (25) sampled Stage II residents. Resident identifiers: #64 and #62. Facility Census: 95. Findings Include: a) Resident #64 During an observation, on 8/13/12 at 5:10 p.m., Resident #64 was observed in the dining area and was served a pureed meal for dinner. She sat and stared at the food, but did not take a bite of anything the entire time she was observed. This table was observed from 5:10 p.m. until 5:55 p.m. This resident was questioned on two different occasions why she was not eating and she replied that I did not want this. The resident did not eat any of her food during that time and there were no staff members observed to come to assist her or to try to encourage her to eat. She was not offered an alternate meal when she did not eat any of the food served to her. The resident was observed to leave her table at 5:55 p.m. She still had not eaten any of the food she was served. She still not been offered assistance or an alternative meal. On 08/14/12 at 3:00 p.m., the meal intake records were reviewed for this resident. According to these records, it was recorded that on 08/13/12 she ate 100% of her dinner. The Director of Nursing was made aware it had been recorded in the medical record this resident had eaten 100% of her meal when she had been observed to eat nothing that was on her tray on 08/13/12 for dinner and was observed leaving her table with her food untouched. b) Resident #62 Medical record review found a nursing assessment had been completed on 06/13/12. According to the nursing assessment, the resident had both upper and lower dentures. Review of the significant change minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/18/12, found the resident had been coded as having no dentures. On 08/15/12 at 2:00 p.m., the DON (director of nursing) was interviewed regarding the conflicting information. The DON stated the nursing assessment was incorrect, the resident had been admitted without upper or lower dentures.",2016-04-01
10494,LAKIN HOSPITAL - STATE,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2011-01-12,431,E,0,1,630F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and a review of Pharmacy Consultation expectations, the facility failed to identify and dispose of outdated medications. This occurred for two (2) of four (4) medications rooms observed and had the potential to affect more than an isolated number of residents. Facility census: 90. Findings include: a) Observation of the medication room on D Wing, with a licensed practical nurse (LPN - Employee #156) on [DATE] at 2:00 p.m., found the following medications with outdated expiration dates: - Tea Tree Oil expired on ,[DATE]; - Mag Delay capsules expired in ,[DATE]; - Lorazepam 2mg/ml, 30ml expired ,[DATE]; - Vaseline expired ,[DATE]; and - Two packages containing Cavicide (located in the treatment cart) expired in ,[DATE]. - b) Observation of the medication room on C Wing, with Employee #27 (an LPN) on [DATE] at 2:30 p.m., found two (2) Acetaminophen 325 mg suppositories expired in ,[DATE]. In addition, a bottle of Peroxide was found on the stock shelf with a broken lid. - c) On [DATE] during the mid-afternoon, an interview with the director of nursing found the facility did not have a policy regarding medication storage expiration dates. She did present for review ""Standards for Consultant Pharmacists"", which she said included the Consultant Pharmacist's expectations. Section 1. Services, Item A.1.c., stated, ""Assure that drug storage rooms, medication carts, IV carts and medical supply areas are maintained in a clean and safe manner and are free of expired and/or discontinued drugs and biologicals.""",2015-03-01
11317,LAKIN HOSPITAL - STATE,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2011-01-12,323,G,1,0,630F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide adequate supervision to prevent an avoidable accident to one (1) of four (4) residents reviewed for swallowing problems. During the evening meal on 12/02/10, dietary staff provided for Resident #83 a mechanically altered meal contrary to his physician order [REDACTED]. Prior to the on-site investigation into this choking incident by the State survey and certification agency, the facility took prompt actions to identify and correct system failures that permitted dietary staff to send the wrong tray to a resident and that allowed the nursing staff to serve the wrong diet, to ensure this type of avoidable accident did not recur. Resident identifier: #83. Facility census: 90. Findings include: a) Resident #83 Review of facility records revealed Resident #83 suffered a choking episode during the evening meal on 12/02/10, which resulted in the need for nursing staff to administer the Heimlich maneuver to expel a bolus of food that obstructed the resident's airway. This choking episode was an avoidable accident, which resulted from the resident receiving and consuming foods that were not pureed in accordance with his physician-ordered therapeutic diet. Interview with the administrator and director of nursing (DON), on 01/10/11 at 3:20 p.m., revealed Resident #83 had resided on the B wing until 12/02/10, when a decline in his condition promoted the facility to transfer him to C wing where his health status could be more closely monitored. When, during the evening meal on 12/02/10, Resident #83's meal tray did not arrive on the new unit (C wing), nursing staff contacted the dietary department to request another tray. Two (2) residents on C wing (Residents #83 and #100) had the same last name. Dietary staff was not aware of Resident #83's room transfer and prepared a tray for Resident #100 (the other resident on C wing with the same last name). Resident #100 had a physician's orders [REDACTED].#83 had a physician's orders [REDACTED]. Nursing staff then proceeded to serve Resident #83 the mechanical soft diet, which resulted in the choking episode. Nursing staff immediately reacted to the choking by performing the Heimlich maneuver, which successfully dislodged the bolus of food that was obstructing Resident #83's airway. Nursing staff immediately notified the physician of the choking episode and received instructions to monitor the resident. On the following day, the resident sustained [REDACTED]. The administrative staff immediately began an investigation into the root cause of this adverse event. A comprehensive investigation by the facility's administrative staff identified that both dietary and nursing staff was responsible for this avoidable accident. The incident was reported to all State agencies as required. The staff members involved received suspensions, all dietary staff was re-educated on the need to carefully prepare meal trays in accordance with each resident's physician-ordered diet, and all nursing staff was re-educated on the need to verify that mechanically altered diets were correct prior to service to each resident, by reviewing each resident's tray card. The system failures that contributed to this adverse event were identified and corrected by the facility prior to this on-site complaint investigation by the State survey and certification agency.",2014-07-01
3767,WAR MEMORIAL HOSPITAL,5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2020-02-05,583,D,0,1,0VLH11,Based on observation and staff interview the facility failed to safeguard the content of Resident personal information displayed on a computer. This is a random opportunity for discovery. Resident identifier: #10. Facility census: 16. Findings included: a) Resident #10 During medication pass on 02/05/20 at 1:20 PM licensed nurse (LPN) #15 used a computer to determine medications to give to Resident #10 and then walked away from the computer to administer the medication. Licensed nurse #15 did close the screen on the computer leaving the residents' medical information available for any person passing by to observe. Interview with licensed nurse #15 on 02/05/20 at 1:30 PM agreed she forgot to clear the computer screen.,2020-09-01
3768,WAR MEMORIAL HOSPITAL,5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2020-02-05,695,D,0,1,0VLH11,"Based on observation and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. An oxygen humidifier bottle was not labeled with a date as to when it was last changed. This practice has the potential to affect a limited number of residents receiving respiratory care services. Resident identifiers: #15. Resident census: 16. Findings included: a) Resident #15 An observation on 02/04/20 at 08:40 AM, revealed the Resident #15 had an oxygen humidifier bottle attached to the wall oxygen flowmeter. There was no date on the oxygen humidifier bottle. An interview with Licensed Practical Nurse (LPN) #15, on 02/04/20 at 8:45 AM, revealed the oxygen humidifier bottle should be changed and dated every seven (7) days. She stated, the night shift nurse is responsible for changing and dating the humidifier bottle. LPN #15 verified the tubing was not dated and immediately changed and dated the humidifier bottle.",2020-09-01
3769,WAR MEMORIAL HOSPITAL,5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2019-04-17,759,D,0,1,R53F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of manufacturer's guidelines, and review of Nursing 2019 drug handbook, the facility failed to maintain a medication administration error rate of less than five percent (5%). The error rate was 7.69% (percent). This was evident for two (2) medication errors out of twenty-six (26) opportunities. Resident identifier: #10. Facility census: 16. Findings included: a) During an observation on 04/16/19 at 7:36 AM licensed practical nurse #30 (LPN #30) handed a [MEDICATION NAME] 160/4.5 microgram inhaler to resident #10. Resident #10 immediately inhaled two (2) puffs of the medication in rapid succession, then rinsed her mouth with water. On 04/16/19 at 7:37 AM LPN #30 handed her a ProAir 90 microgram inhaler. The resident again immediately inhaled two (2) puffs of the medication in rapid succession, then rinsed her mouth with water. Review of manufacturer's instructions for [MEDICATION NAME] administration found directives to wait at least one (1) minute between successive inhalations for maximum effectiveness. Review of manufacturer's instructions for ProAir administration found directives to wait at least one (1) minute between successive inhalations for maximum effectiveness. Review of the Nursing 2019 handbook which was kept at the nurses' station for reference, found directives that if using other inhalers at the same time, wait at least two (2) minutes between the use of each medication. An interview was conducted with the director of nursing (DON) on 04/16/19 at 8:55 AM. She said this resident will not allow nurses to administer inhalers. Rather, the resident uses her inhalers in the presence of the nurses. Upon inquiry, the DON said she did not know if anyone had educated the resident on the correct spacing of the inhaled medications. She said the facility has no policy or procedure about the spacing of inhaled medications. On 04/17/19 at 12 PM the DON stated that nursing completed education with the resident today as to the correct use of inhaled medications. The DON stated that the resident told her she used the inhalers at the facility the same way she used them at home prior to coming to the facility, and did not realize there was a more effective way to use them.",2020-09-01
3770,WAR MEMORIAL HOSPITAL,5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2019-04-17,812,F,0,1,R53F11,"Based on observation, staff interview, and policy review, the facility failed to store food in accordance with professional standards of food safety. There were multiple items in the walk-in cooler which were stored beyond the use by date, not dated when opened, and/or stored beyond the manufacturer's sell by date. This had the potential to affect all of the resident's in the facility. Facility census: 16. Findings included: a) Initial Tour of the Kitchen An initial tour of the kitchen on 04/15/19 beginning at 11:00 AM and concluding at 11:31 AM with dietary employee #23, found the following concerns in the walk-in refrigerator: 1. An opened, partially used plastic bag of cubed Swiss cheese, which weighed approximately two (2) pounds, was dated as having first been opened for use on 03/31/19. Its label directed to use by 04/09/19. 2. A clear, plastic, four (4) quart bowl was filled to the two (2) quart line with kidney beans. This bowl of beans was dated 04/07/19, with directions to use by 04/13/19. 3. An opened, partially used plastic bag of shredded mozzarella cheese, which weighed approximately one (1) pound, was dated as having first been opened for use on 04/05/19. Its label directed to use by 04/12/19. 4. An opened, partially used plastic bag of cubed cheddar cheese, which weighed about half a pound, was dated as having first been opened for use on 04/04/19. Its label directed to use by 04/13/19. 5. An opened, partially used plastic bag of Romano cheese, which weighed about one (1) pound, was dated as having first been opened for use on 03/29/19. Its label directed to use by 04/07/19. 6. An opened, nearly full gallon jug of Dairy Pure 2% reduced fat milk was labeled to sell by 04/08/19. There was no date to indicate when it was first opened for use. 7. An opened, nearly empty gallon jug of whole milk was labeled to sell by 04/15/19. There was no date to indicate when it had first been opened for use. There was approximately three (3) inches of milk which remained in the bottom of the milk jug. The above listed food items were shown to dietary employee #23 on 04/15/19 at 11:31 AM. She agreed the first five (5) items named above should have been discarded by the use by dates inscribed. She agreed that the milk items listed in number six (6) and in number seven (7) should have been dated when initially opened. She immediately began to dispose of those seven (7) items. An interview was conducted with the dietary manager on 04/16/19 at 3:00 PM. She was aware that dietary employee #23 discarded those seven (7) named food items yesterday. On 04/17/19 the facility provided a copy of the Food Storage and Refrigerator Safety policy and procedure which was most recently reviewed in 02/2019. Under section [NAME], Practices to maintain safe refrigerated storage, item number seven (7) included Labeling, dating and monitoring of refrigerated food, so it is used by the expiration date or discarded.",2020-09-01
3771,WAR MEMORIAL HOSPITAL,5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2018-05-09,812,F,0,1,ONYB11,"Based on observation and staff interview, the facility failed to prepare and serve food in a sanitary manner. This had the potential to affect any resident who receives nourishment from the dietary kitchen. Facility census: 16. Findings included: a) Lunch tray serve line observation in the kitchen On 05/08/18 at 11:50 a.m., water was observed on the floor beside the tray serve line in the dietary kitchen. Cook Employee #10's (E#10) work station on the food serve line ensured that she stood between the tray line and the water spill on the floor. At this time of observation, E#10 was in the process of assisting to serve food to the residents and to the patients in the hospital. She wore purple-colored latex gloves during the food tray serve to ensure her bare hands did not come into direct contact with resident's or hospital patient's food or items on the tray. At 11:50 a.m. on 05/08/18, E#10 used a white-colored cleaning cloth to mop the water spill on the floor, while wearing her purple-colored latex gloves. After she wiped the spill thoroughly, E#10 carried the wet cloth into the area which housed the dishwashing machine and disposed of the now wet, dirty, cleaning cloth. E#10 immediately returned to her station on the tray line serve, to resume serving the lunch meal to residents. As she reached for a clean plate, she wore the same purple-colored latex gloves which she wore while wiping the water spill on the floor. Upon inquiry as to whether she should change gloves and wash hands now, she replied in the affirmative and thanked the questioner for the reminder. On 05/08/18 at 12:22 p.m., an interview was conducted with the dietary manager, Employee #59. She said Employee #10 should have washed hands and changed gloves after wiping up the water on the floor. E#59 said the water on the floor came from condensation from the steamer, which is located across from the tray line. She said that all dietary staff have received on-going in-service education on cleanliness and infection control, which included hand hygiene principles.",2020-09-01
4887,WAR MEMORIAL HOSPITAL,5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2016-03-11,225,F,0,1,LRMX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel file review, facility policy/procedure review, review of Chapter 514.4 of the Medicaid manual and a clarification memorandum from the Bureau for Medical Services (BMS) regarding the requirements of the Affordable Care Act, and staff interview, the facility failed to ensure criminal background investigations were completed for all employees prior to hire and every 3 years there after throughout the remainder of employment to determine whether the individuals had been found guilty of abuse, neglect, or mistreatment of [REDACTED]. This was not completed for one (1) of ten (10) employees whose personnel files were reviewed. Employee identifier: #48. Facility census: 16. Findings include: a) Employee #48, Rehabilitation Physical Therapy Aide (Rehab PTA) Review of the personnel files on 03/08/16 at 3:50 p.m. with Senior Human Resources Director (SRD #159), revealed Rehab PTA #48's file lacked a criminal background check. SRD# 159 stated, I will not be here tomorrow but will research and provide the criminal background check. On 03/09/16 at 8:55 a.m., the Administrator provided copies of communication from the West Virginia State Police to Rehab PTA #48. A copy of an email sent to an employee in the Human Resources Department on 02/18/14 from WV Easypath-Morpho Trust with a letterhead from the West Virginia State Police. The FBI (Federal Bureau Investigations) has rejected the fingerprint submission and the employee must be re-fingerprinted. A review of the facility Resident Abuse/Neglect policy and procedure on 03/09/16 at 9:00 a.m. stated; .D. Miscellaneous Screening Efforts 1. as part of the pre-employment process, all applicants for employment on the long term care facility will have a criminal conviction investigation completed and a complete set of fingerprints. On 03/09/16 at 9:10 a.m. the Director of Nursing (DON) stated, We do not have anything on her (Rehab PTA #48) for any background checks. She has been working with out a background check on file since her hire date (hire date 06/26/1984). 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment ). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on (MONTH) 15, 2013. The memo included . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility until (MONTH) 1, 2014, to have all current employees up to date with criminal investigation background checks. For any new hires in the nursing facility, the policy is effective for those individuals as of (MONTH) 1, 2013",2019-07-01
4888,WAR MEMORIAL HOSPITAL,5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2016-03-11,371,E,0,1,LRMX11,"Based on observation and staff interview the facility failed to ensure food was served under sanitary conditions. An employee did not practice proper hygienic practices by not keeping their hands away from their hair and face when serving meals. This practice had the potential to affect all residents who received food from the kitchen. Facility census: 16. Findings include: a) During observation of the noon meal service, on 03/08/16 at 12:00 p.m., Activities Director (AD) #146 was observed serving lunch trays to the residents in the dining room and the residents' rooms. AD #146 pushed her long unsecured hair behind her ear each time she retrieved a lunch tray from the meal cart. In addition, her long unsecured hair touched the meal trays as she delivered each tray to the residents. At 12:02 p.m. on 03/08/16, Licensed Practical Nurse (LPN) #16 confirmed AD# 146 was touching her hair every time she retrieved a lunch tray from the meal cart. On 03/08/16 at 12:05 p.m. AD# 146 acknowledged she was pushing her hair back while pulling meal trays from the food cart. She immediately obtained a hair clip and pulled her hair back before delivering the remainder of the lunch trays. During an interview on 03/09/16 at 8:00 a.m. Infection control nurse #97 stated, Our policy is their hair is to be pulled back when serving meals.",2019-07-01
6225,WAR MEMORIAL HOSPITAL,5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2015-02-04,272,D,0,1,Y4QQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a Significant Correction to a Prior Quarterly Assessment (SCQA) after the Interdisciplinary Team (IDT) determined the resident's recent assessment contained a significant error identifying a change in her condition. Resident #19's minimum data set (MDS) assessment was incorrect related to independent functioning. Resident identifier: #19. Facility census: 16 Findings include: a) Resident #19 Review of the resident's medical record, on 02/03/15 at 2:00 p.m., found her quarterly minimum data set (MDS), with an assessment reference date (ARD) of 01/01/15, indicated her ability to function independently with bed mobility, transfers and toileting had declined since the prior assessment with an ARD of 10/02/14. The prior assessment indicated she required limited to extensive assistance to complete these functions. A progress note, dated 01/15/15, stated the Quarterly MDS with an ARD of 01/01/15 was incorrectly coded to indicate the resident needed extensive assistance with bed mobility, toileting, and dressing. The resident was re-evaluated and found to require only supervision to limited assistance with all of her activities of daily living (ADLs). The Centers for Medicare and Medicaid Services (CMS) resident assessment instrument (RAI) version 3.0 manual dated October 2014 states on page 2-32, The Significant Correction to Prior Quarterly Assessment (SCQA) is an Omnibus Budget Reconciliation Act (OBRA) non-compliance assessment that must be completed when the IDT determines that a resident's prior assessment contains a significant error A significant error is an error in an assessment where: 1. The resident's overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment; and 2. The error has not been corrected via a submission of a more recent assessment. No documentation was found indicating the facility filed a correction. Nurse aide #18, reported Resident #19 was pretty much independent with all of her ADL care, during an interview on 02/03/15 at 2:13 p.m. In an interview with the MDS nurse, Employee #7, on 02/03/15 at 2:30 p.m., she confirmed the assessment dated [DATE] was coded incorrectly, as nursing assistant documentation showed the resident was more independent in ADLs than the MDS indicated. She acknowledged she had not submitted a correction after the therapy department reevaluated the resident and verified she did not decline in her ADL functions.",2018-05-01
6601,WAR MEMORIAL HOSPITAL,5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2013-10-17,279,D,0,1,9QWX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop measurable goals for the care plan for one (1) of five (5) residents reviewed for unnecessary medications. The care plan identified Resident #2 had problematic behaviors and received antipsychotic medication daily. The care plan contained no measurable goals for which treatment and interventions were being provided related to the behaviors. Resident identifier: #2. Facility census: 15. Findings include: a) Resident #2 The medical record was reviewed for Resident #2. This resident was diagnosed with [REDACTED]. This was defined by specific behaviors as quantitatively (number of episodes) and objectively (such as biting biting, kicking, and scratching) documented by the facility which cause the resident to actually interfere with staff's ability to provide care. This resulted in the initiation of [MEDICATION NAME] (an antipsychotic medication) 25 milligrams (mg) daily. The [MEDICATION NAME] was begun on 09/28/13. Review of the care plan revealed this resident had repetitive obsessive behaviors. Numerous behaviors and interventions to treat the behaviors were identified on the care plan. However, the care plan contained no goals related to potential outcomes as the result of using the antipsychotic medication and the non-pharmacological interventions. On 10/16/13 at 2:10 p.m., an interview was completed with a licensed nurse, Employee #16. She said this resident had been sleeping during the day, especially when up to activities. She said she had noticed an improvement in the resident's activity participation and wakefulness over the past few weeks. An interview was conducted with the consultant administrator (Employee #48) on 10/16/13 at 2:15 p.m. She said this resident had been awake a good bit during the nights while displaying repetitive, obsessive behaviors. Numerous non-pharmacological interventions were tried by staff, to no avail. As a result of these obsessive, repetitive behaviors during the nights, she would then be too tired by day to take part in activities she once enjoyed. She said since beginning the [MEDICATION NAME] a few weeks ago, this resident had been getting more rest at night. Subsequently, the resident was more wakeful, active and able to socialize more by day. Employee #48 said she believed the resident's quality of life had improved since beginning the [MEDICATION NAME]. On 10/16/13 at 4:20 p.m., an interview was completed with the Director of Nursing (DON) and Employee #48. They acknowledged there were no measurable goals on the care plan related to the obsessive behaviors. They agreed there were no non-pharmacological interventions noted on the psychoactive medication monthly flow record, as there was not a place for that information. They said non-pharmacological interventions would be documented in the nurses' progress notes. However, since beginning the [MEDICATION NAME] on 09/28/13, there was no evidence staff were consistently trying non-pharmacological methods to address the behaviors. There were nineteen (19) shifts in October on the monthly flow record with documented obsessive behaviors. Review of nurses' progress notes for those shifts found no evidence of which, if any, non-pharmacological interventions may have been tried. Employee #48 said it was such a small facility, staff would just know what worked for the resident. She said staff should have documented the interventions, to receive credit for what they did. She added this issue would be addressed.",2018-01-01
6602,WAR MEMORIAL HOSPITAL,5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2013-10-17,428,D,0,1,9QWX11,"Based on medical record review and staff interviews, the facility failed to ensure the pharmacist identified and reported irregularities to the physician and the director of nursing for two (2) of five (5) Stage 2 sample residents reviewed for unnecessary medications. Each of these residents used antidepressant medications for an excessive period of time without an attempt at a gradual dose reduction. There was no evidence the pharmacist identified this and recommended the consideration of a gradual dose reductions. Resident identifiers: #5 and #13. Facility Census: 15. Findings Include: a) Resident #5 Review of Resident #5's medical record revealed the resident was prescribed the antidepressant Zoloft since 01/14/11. The pharmacist's monthly drug regimen reviews, from December 2012 through October 2013 revealed no indication the pharmacist had made a recommendation for a gradual dose reduction for this medication. The records did not identify a history of failed dose reductions of the Zoloft. b) Resident #13 Review of Resident #13's medication administration records revealed the resident was prescribed the antidepressant Lexapro since 07/08/11. The resident's drug regimen reviews revealed no indication the pharmacist had made any recommendations for a gradual dose reduction for this medication. The resident's records did not identify a history of any failed dose reductions of the Lexapro. c) During an interview on 10/17/13 at 9:40 a.m., the administrator, Employee #48, stated the facility had focused on anti-psychotics and did not complete gradual dose reduction reviews on anti-depressants. An interview on 10/16/13 at 4:40 p.m., with the facility pharmacist, Employee #50, revealed she had not completed gradual dose reduction recommendations on antidepressants due to being focused on antipsychotics.",2018-01-01
8618,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2012-12-07,221,D,0,1,L97I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure a restraint was used only as required to treat medical symptoms for one (1) of fourteen (14) sample residents. The resident was restrained in a tilt geri-chair. There was no assessment prior to initiating the physical restraint, and no physician's order reflecting the presence of a medical condition to warrant the restraint use. The faciilty also was unable to provide evidence the responsible party was made aware of the potential risks and benefits of restraint use. Additionally, there was no care plan to re-evaluate the need for the restraint and no systematic plan to reduce the use of the restraint. Resident identifier: Resident #1. Facility census 16. Findings include: a) Resident #1 Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. The resident had been deemed to lack capacity to make her own health care decisions for the past several years. She was alert at times but, was not oriented to person, place and time. A Brief Interview for Mental Status (BIMS) had not been attempted because of rambling incoherent speech. The resident exhibited both short and long term memory loss. She also exhibited repetitive body and limb movements daily. The resident's care plan included the use of a bed alarm, a low bed with floor mats, and the daily use of a chair to prevent rising. This chair was identified as a physical restraint in both the care plan and the minimum data set (MDS) assessments dated 04/22/12, 07/22/12, and 10/22/12. There was no physician's order reflecting the presence of a medical symptom that would necessitate the use of a physical restraint. There was no evidence in the record that the responsible party for Resident #1 was informed of the risks and/or benefits associated with the use of a restraint, and no evidence the resident was assessed for the suitability of this particular restraint. There was no evidence the use of the restraint had been periodically evaluated for elimination or, that alternative measures had been considered in an attempt to reduce the restraint. During a staff interview with Employee #9 (nursing assistant) at 3:50 p.m. on 12/04/12, she agreed the resident could not rise and exit the geri-chair when it was tilted back. She stated the resident was in the geri-chair in a tilted position whenever she was out of bed. The Director of Nurses (DON) and the Social Worker (SW) were interviewed at 8:45 a.m. on 12/06/12. They agreed, after reviewing the record, they failed to secure a physician's statement of a medical symptom necessitating the restraint, and confirmed they could not locate documentation of an assessment for the use of the restraint. They could provide no evidence information had been provided to the responsible party (daughter) prior to use of the tilt chair but, stated she visited almost daily and was aware of the use of the tilt chair. The resident's daughter was not seen at the facility during the survey.",2016-05-01
8619,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2012-12-07,248,D,0,1,L97I11,"Based on observation, medical record review, and staff interview the facility failed to provide an ongoing program of activities to meet the interests and psychosocial well-being as outlined in the resident's care plan for one (1) of three (3) residents reviewed for the care area of activities during stage two (2) of the survey. The resident's care plan noted several activity preferences, including baseball games, sports and Catholic mass on TV, music, and one-to-one interactions with staff. There was no evidence the resident was provided these activities. Resident identifier: Resident #7. Facility census: 16. Findings include: a) Resident #7 Random observations during the afternoon of 12/03/12 and throughout the day on 12/04/12 found the resident always in bed in his room. There was a television and a radio in the room, but neither were playing. Review of the medical record revealed the resident was bedridden and dependent on staff for all activities of daily living (ADLs) including social interactions and turning on audiovisual stimulation. The Care Area Assessment (CAA), dated 06/18/12, identified the resident's activity choices as one-on-one visits with family, staff, and his dog, baseball games and Catholic mass on television (TV), and music. The current care plan, dated 09/14/12 addressed the resident's activity preferences of baseball games, sports and Catholic mass on TV, music, and one-to-one interactions with staff. Review of the resident's daily participation records, on 12/05/12, for August, September, and October 2012 revealed the only activity noted was observed for Movies/TV/Radio for nearly every day. In November 2012, the same observed for Movies/TV/Radio was noted nearly every day. In addition, the activity participation record noted the resident was active for Coffee/Goodie Cart. When asked how the resident participated in the Coffee/Goodie Cart, on 12/05/12 at 8:20 a.m., the social worker/activity director (Employee #23) stated this cart was taken around to the residents, and drinks were offered. Due to the resident's mental status, this resident could not have selected a beverage when offered. A follow up observation on 12/05/12 at 10:00 a.m., after discussing the concern regarding the provision of activities for this resident with Employee #23, found someone had turned on the resident's television.",2016-05-01
8620,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2012-12-07,272,D,0,1,L97I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview, the facility failed to ensure the accuracy of the minimum data set (MDS) for one (1) of three (3) residents reviewed in the area of vision during stage 2 of the survey. Resident identifier: Resident #7. Facility census: 16. Findings include: a) Resident #7 Review of the medical record, on 12/05/12, identified the resident had a history of [REDACTED]. The Care Area Assessment (CAA) tool dated 06/18/08 noted the inability of the assessor to assess vision because the resident was unable to follow one-step commands. The current CAA dated 06/19/12 identified the resident wore glasses at one time. Review of the annual MDS, dated [DATE] and the quarterly MDS, dated [DATE], under section B1000, vision, found an entry code of 2, which indicated: impaired - sees large print, but not regular print in newspapers/books. An interview with the resident's daughter, on 12/04/12 at 4:00 p.m., confirmed the resident had a history of [REDACTED]. During an interview, on 12/05/12 at 8:46 a.m., with the MDS Registered Nurse (RN) Employee #2, she acknowledged she was unaware how to code the vision assessment on the MDS for a resident that was unable to communicate. The MDS guidelines indicate if the resident is unable to communicate, section B1000 should be coded #3, not #2. .",2016-05-01
8621,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2012-12-07,278,D,0,1,L97I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the minimum data set (MDS) registered nurse (RN), Employee #2 failed to ensure the accuracy of the MDS for one (1) of three (3) residents reviewed in the area of vision during stage 2 of the survey. Resident identifier: #7. Facility census: 16. Findings include: a) Resident #7 Review of the medical record, on 12/05/12, identified the resident had a history of [REDACTED]. The Care Area Assessment (CAA) tool, dated 06/18/08, noted the inability of the assessor to assess vision because the resident was unable to follow one-step commands. The current CAA, dated 06/19/12, identified the resident wore glasses at one time. Review of the annual MDS, dated [DATE] and the quarterly MDS, dated [DATE], under section B1000, vision, found an entry code of 2, which indicated: impaired - sees large print, but not regular print in newspapers/books. During an interview, on 12/05/12 at 8:46 a.m., with the MDS Registered Nurse (RN) Employee #2, she stated she was unaware how to code the vision assessment on the MDS for a resident who was unable to communicate. The MDS guidelines indicate if the resident is unable to communicate, section B1000 should be coded #3, not #2. .",2016-05-01
8622,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2012-12-07,279,E,0,1,L97I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a complete care plan addressing all identified problems by not including measurable goals and/or acceptable interventions for four (4) of fourteen (14) stage 2 sampled residents. Resident identifiers: Residents #9, #1, #2, and #7. Facility census 16. Findings include: a) Resident #9 Review of the medical record for Resident #9 revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident had been receiving the medication [MEDICATION NAME] 1.25mg PO (by mouth) every evening for agitation since 10/25/2011. The medication was discontinued on 10/24/12, for a trial period at the request of the pharmacist who stated the following in a Psychoactive Pharmacy Drug Review: Olanazepin 1.25mg q hs (every night) with behavior noted by nursing notes as pleasant and cooperative. The medication was restarted on 11/14/12, when the resident was again exhibiting behaviors. Review of the current care plan revealed the facility had not adequately addressed the use of psychoactive medications. Although the medication was mentioned as an intervention associated with particular problems, the care plan did not describe problems that could arise from the use of the psychoactive medication, such as common side effects of the medication to which staff should be alerted. During an interview with the director of nurses (DON), at 4:00 p.m. on 12/06/12, she acknowledged, after reviewing the care plan, that it did not directly address psychoactive medications and problems that could arise from their use. b) Resident #1 Review of the medical record revealed Resident #1 was admitted to the facility, on 04/21/04, with a [DIAGNOSES REDACTED]. To treat those behaviors she was receiving [MEDICATION NAME] three (3) times daily. A review of her care plan revealed the following entry, dated 11/04/09, under Problems: Cognition, Behavior, Mood, & Psychoactive Drug Use: however, there was no measurable goal established for the use of psychoactive medications. The interventions included: Monitor for medication induced side effects and document behavior on Psychoactive Medication Record and Behavior Monitoring Record, and AIMS assessment every six (6) months, does exhibit extra pyramidal symptoms. The pharmacist reviewed the psychoactive medication use on 10/11/12, and suggested a change in the medication and/or dosage due to repetative tongue movements reported by the dietitian. The physician lowered the dosage of the [MEDICATION NAME] on 10/25/12, but no changes were made to the care plan. A measureable goal related to this was not established. During an interview with the DONat 4:00 p.m. on 12/06/12, she acknowledged, after reviewing the care plan, that although there was an entry for psychoactive medications in the problems, there had NOT been a measurable goal set. She stated she would talk to the pharmacist about doing so. c) Resident #6 On 12/06/12 at 2:30 p.m., a review, of the care plan for Resident #6, revealed there was no problem statement, goal, and/or interventions for [MEDICATION NAME] (a heart medication). d) Resident #2 During an interview, on 12/03/12 at 2:48 p.m., this resident stated she had a hard time chewing food because of her old teeth. A review of the medical record, on 12/06/12, revealed the resident had dental problems which might affect her nutrition intake. The care plan, dated 10/25/12, identified the resident's oral care, including dental visits, but lacked measurable goals to meet the resident's needs regarding her dental problems. During an interview, on 12/06/12 at 12:50 a.m. with licensed practical nurse (LPN) #19 she stated, staff assists resident with meal selection every week and the resident has never reported any difficulty with eating certain foods. Normal routine is to offer the resident another selection if she does not eat her meal. e) Resident #7 Review of the medical record revealed the resident is bedridden and dependent on staff for all activities of daily living (ADL) including social interactions and audiovisual stimulation. The Care Area Assessment (CAA) dated 06/18/12 identifies the resident's disease process and lists his choices as one on one visits with family, staff, and his dog; baseball games and catholic mass on television (TV); and music. Current care plan dated 12/14/12 lacks measurable goals and a time table related to activities for the resident. The care plan states staff will turn the television (TV) on for baseball games, sports and catholic mass, music is at the bedside and provided by the family, and the resident will receive one to one interactions with his family and/or the staff. The resident's daily participation records for August, September, October and November 2012, were reviewed by the social worker/activities director employee #23 during an interview on 12/05/12 at 9:20 a.m. She stated The nursing assistants haven't been filling them out.",2016-05-01
8623,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2012-12-07,280,D,0,1,L97I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to review, assess the effectiveness of, and revise the care plan when two (2) of fourteen (14) sampled residents had changes in their healthcare needs. Resident identifiers: #1 and #12. Facility census 16. Findings include: a) Resident #1 A review of the record revealed that Resident #1 had been admitted on [DATE]. The resident was observed at 4:00 p.m. on 12/03/12, sitting in a tilted back geri chair in her room. She moves her body and limbs with jerky movements and calls out occasionally. She was being fed a pureed diet by a nursing assistant. During an interview with Employee #9 (nurse aide) at 3:50 p.m. on 12/04/12, she stated the resident stayed up a large part of the day and was in the tilted geri-chair because she would try to reach her feet to take off her socks and staff were afraid she would fall out of the chair. The aide stated that this had been the daily practice for the four (4) months she had worked at the facility. During an interview with Employee #1 (Registered Nurse) at 6:45 a.m. on 12/05/12, the nurse stated they had found when the chair was tilted back, the resident could not fall out as she had in the past. The nurse did not remember how long they had been doing this, but at least for several months. She stated the resident exhibited these repetitive movements daily. A review of the current care plan dated 05/07/09 - 01/03/13 revealed the following interventions regarding the geri-chair: During periods of agitated behavior, tray table to be up when up in geri chair ., While resident is up in geri-chair staff will check resident at least every hour and will assist and provide ADLs, fluids, toileting, and meals. When sitting up in chair, resident's feet will be supported by foot rest if chair is not reclined., and Chair alarm when up in chair (when tray table not in use) to notify staff that resident needs assistance. There is nothing in the care plan about using the tilt position when the resident is in the geri-chair, although it was observed in use daily. The annual MDS (minimum data set) section P0100G is marked for a restraint, described Chair Prevents Rising and the CAA (care area assessment)indicated that it would be addressed in the care plan. During an interview with the Director of Nursing (DON) at 8:45 a.m. on 12/06/12, these findings were discussed. At 9:30 a.m. during a follow-up interview with the DON and Social Worker they agreed, after reviewing the record, the use of the tilt-chair had not been addressed in the resident's care plan. b) Resident #12 A review of the medical record revealed Resident #12 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her annual screening by Rehabilitation Services on 08/29/12, indicated that her left hand was contracted and suggested continuing the use of a splint on this hand, although the resident removed it at times. The active physician's orders [REDACTED]. This order was added on 09/30/11. The care plan was not revised to include the presence of a contraction with a measurable goal. The care plan continues to include Arm sling to left arm while up and Adjustable resting splint to (L) hand/wrist 20 - 24 hours per day to manage (L) digits and wrist in neutral position. Employee #1 (Registered Nurse) stated at 6:30 a.m. on 12/05/12, that the sling or the splint were no longer used because the resident would not leave them on. The resident was observed daily during the survey and a sling or splint was at not time in place. At 9:50 a.m. on 12/06/12, Employee #19 (nurse) was asked to locate the sling and splint in the resident's room. After searching, she did locate a clean sling and sheepskin hand wrap in a storage cabinet in the room, but she and the DON, who was also present, agreed the staff were not attempting to use them on a regular basis. During an interview, shortly after, the DON acknowledged that the care plan had not been revised to accurately describe the care of the resident.",2016-05-01
8624,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2012-12-07,282,D,0,1,L97I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to ensure the interventions in the Care Plan were carried out for one of fourteen sampled residents, making an accurate evaluation of the interventions difficult. Resident identification: #12. Facility census 16. Findings include: a) Resident #12 A review of the medical record revealed that Resident #12 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her annual screening by Rehabillation Services on 08/29/12, indicated that her left hand was contracted and suggested continuing the use of a splint on this hand, although the resident removed it at times. The active physician's orders [REDACTED]. This order was added on 09/30/11. The care plan continues to include Arm sling to left arm while up and Adjustable resting splint to (L) hand/wrist 20 - 24 hours per day to manage (L) digits and wrist in neutralposition. Employee #1 (Registered Nurse) stated at 6:30 a.m. on 12/05/12, that the sling or the splint were no longer used because the resident would not leave them on. During an interview with Employee #17 (nurse aide) at 6:30 a.m. on 12/05/12, she stated that they no longer applied the sling or splint because the resident would just remove them. During an observation of the resident at 8:20 a.m. on 12/5/12, the resident was being positioned and served her meal. The resident exhibits limitations on her left and did not have a splint on. The resident was observed daily during the survey and never had either a sling or splint applied. At 9:50 a.m. on 12/06/12, Employee #19 (nurse) was asked to locate the sling and splint in the resident's room. After searching, she did locate a clean sling and sheepskin hand wrap in a storage cabinet in the room, but she and the DON, who was also present, agreed that the staff were NOT attempting to use them on a regular basis. During an interview, shortly after, the DON acknowledged that the care plan was not being followed by the aides, but stated that she needed to speak to the physician and change the order and the care plan.",2016-05-01
8625,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2012-12-07,286,F,0,1,L97I11,"Based on record review and staff interview the facility failed to assure that all portions of the medical record of all residents was readily and easily accessible by all professional staff members by limiting the access to the Minimal Data Set (MDS) which includes the comprehensive assessment information. This has the potential to affect all residents. Facility census 16. Findings include: a) During the initial interview with the Director of Nurses at 12:30 p.m. on 12/03/12, she informed this surveyor that all aspects of the record were available on the chart except the MDS which was in the computer and hard copies are no longer being produced for the chart. During a discussion of accessing the MDS on the morning of 12/05/12, with Employee #4 (Licensed Practical Nurse) she stated that she would have to request someone to do this as she did not have access to the computer. This was verified with the DON, who stated that only she, the unit clerk, and the MDS nurse have entry to the computer. When asked, she stated that they all worked day shift. She acknowledged that they had not considered the lack of access by the nursing staff caring for the resident when the decision was made not to print hard copies of the MDS for the chart.",2016-05-01
8626,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2012-12-07,329,E,0,1,L97I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy and procedure, the facility failed to ensure that medication regimens were free from unnecessary drugs. This includes duplicate therapy, excessive duration, and lack of adequate indications for administration as well as incomplete orders. In addition, the facility failed to ensure that residents receiving antipsychotic drugs receive gradual dose reduction unless clinically contraindicated. This is true for four (4) of eleven (11) stage two (2) sampled residents. Resident identifiers: Resident #5, #16, #3, and #2. Facility census sixteen (16). Findings include: a.) Resident #5 A record review performed on 12/4/12 of physician's order [REDACTED]. No indication for usage was listed. The medication administration records (MARs) for October 2012 and November 2012 verify this medication was never administered during that time period and no stop date was provided. Another order dated 11/22/2010 for Tylenol 650 mg suppository was incomplete as it did not specify a route for administration. This information was discussed with the Director of Nursing (DON) on 12/5/12 at 2:30 p.m. and she was unable to provide further information. According to the facility policy and procedure titled Stop Orders , All PRN {as needed} orders, except for [MEDICATION NAME], are discontinued in 60 days if not utilized at all during that time, unless the prescriber specifically orders them to be continued indefinitely or for a specified period of time. b.) Resident #16 Resident #16 was admitted on [DATE] with an order for [REDACTED]. A second request from pharmacy dated 10/16/12 stated Consider dose reduction or drug holiday . It was not until 10/22/12 that the dosage of [MEDICATION NAME] was reduced to 0.25 mg every morning, over two months after the initial recommendation. During the period from initial request to dose reduction, there was no evidence to suggest the reduction was contraindicated. In fact, according to Psychoactive medication monthly flow record for August 2012 through October 2012, no behaviors were documented by nursing. A staff interview was performed on 12/4/12 at 4:00 p.m. with Staff Pharmacist who verified accuracy of all information. In addition, an order was in place for [MEDICATION NAME] suppositories 25 mg 1 PR {per rectum} every 6 hours prn {as needed}. Nausea . This order was dated 8/4/12. I had not been administered during October or November, 2012. No stop date was listed. As per facility policy and procedure, all as needed medications not used in past sixty (60) days are to be discontinued. c.) Resident #3 [MEDICATION NAME] 25 mg twice a day was among the list of medications ordered for Resident #3 upon admission 2/22/12. It was not until 8/14/12 when Pharmacy first addressed [MEDICATION NAME] and stated it was still appropriate as Resident #3 was having hallucinations. On 10/11/12 pharmacy made a recommendation for the physician to try and taper the [MEDICATION NAME]. On 10/24/12 the physician completely discontinued the [MEDICATION NAME]. On 10/25 there was a physician's order [REDACTED]. This was discussed and verified with the Pharmacist on 12/4/12 at 4 p.m. In addition, Resident #3 had physician orders [REDACTED]. There is no order to specify under what situation the nurse should apply Preparation H and when to apply the [MEDICATION NAME]. The Preparation H order is incomplete and does not include a site where to apply, nor does it have a stop date. The original order was written 9/9/2005. The [MEDICATION NAME] order also does not have a stop date and is dated 4/1/2009. An order dated 3/1/11 stated [MEDICATION NAME] Cream to vaginal area and labia PRN {as needed} . This order has no stop date and gives no indication as to what symptoms constitute as needed . These orders were discussed with the DON on 12/5/12 at 2:30 p.m. and she had no further information. The policy clearly states that all as needed medications not used in sixty (60) days will be discontinued. According to the Medication Administration Record [REDACTED]. d) Resident #2 Review of the medical record on 12/06/12 revealed the following prn medications: [REDACTED]. [MEDICATION NAME] 4 mg was administered once between 08/01/12 and 11/30/12 on 09/29/12 and currently remains on the residents MAR indicated [REDACTED] The pharmacy reconciliation notes dated 01/12/12 through 12/04/12 verifies the pharmacist failed to recognize and notify the physician to discontinue prn medications which were not used for 60 days as the policy states. During a staff interview on 12/06/12 at 9:30 a.m. with the Director of Nursing (DON) employee #11 she acknowledged they were not following the facility's policy which is to automatically stop prn medications after thirty (30) days. The pharmacy policy received on 12/06/12 at 10:27 a.m. from the DON employee #11, states All new medication orders are subject to automatic stop orders unless the medication orders specify the number of doses or duration of medication. A time limit is included in recapped orders. All prn medication orders, except for [MEDICATION NAME], are discontinued in 60 days if not utilized at all during that time, unless the prescriber specifically orders them to be continued indefinitely or for a special period of time.",2016-05-01
8627,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2012-12-07,332,D,0,1,L97I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record and facility policy review, the facility failed to administer medications at an error rate of less than 5% for two (2) residents. Three (3) errors were observed for ten (10) residents with 58 opportunities for a medication error rate of 5.17%. Resident identifiers: #6, and #16. Facility census: 16. Findings include: Error #1 and #2 On 12/05/12 at 8:30 a.m., medications were observed being given to Resident #6 by a licensed practical nurse (LPN), (Employee #4). The resident's medications included Potassium Chloride (KCl) 10 milliequivalent (meq) orally. Resident #6 was also given [MEDICATION NAME] 0.125 mg (milligrams) orally. Employee #4 completed a radial pulse check and stated the residents pulse was 64. When Employee #4 was asked what the facility policy was regarding the amount of fluids to be given with KCl and checking the heart rate prior to giving the [MEDICATION NAME] she stated it was not specified. This employee also stated there was no specified policy regarding the amount of fluids to be given when administering KCl. Errors #3 On 12/05/12 at 8:50 a.m., medications were observed being given to Resident #16 by a licensed practical nurse (LPN), (Employee #4). The resident's medications included KCl 10 meq orally. When Employee #4 was asked what the facility policy was regarding the amount of fluids to be given with KCl she stated there was no specified policy regarding the amount of fluids to be given when administering KCl. In an interview with the director of nursing (DON), on 12/05/12 at 10:00 a.m., the DON stated all staff knew an apical pulse was to the taken prior to giving [MEDICATION NAME]. The DON further stated she was unaware of any fluid requirements when administering KCl other than laboratory requirements. The DON stated she would provide a copy of the facility policy and procedure for the administering of [MEDICATION NAME] and KCl. On 10/05/12 at 10:30 a.m., a review of the facility policy and procedure titled, Medication Monitoring, under STATEMENT OF PROCEDURE 1. [MEDICATION NAME] Check apical pulse immediately before administering, with the resident at rest. If the pulse . 10. POTASSIUM SUPPLEMENTS Obtain serum electrolytes every six months unless the physician orders differently. Contact the physician . A concurrent review of the facility policy titled Oral Medication Administration Procedure, revealed under section 6. Follow all medication with 4-8 ounces of water. Preparation containing iron are .",2016-05-01
8628,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2012-12-07,364,E,0,1,L97I11,"The facility failed to provide pureed foods attractive in appearance. This was true for four (4) of nine (9) residents. Resident identifiers: Resident #1, #9, #6, #15. Facility census sixteen (16). Findings include: a.) During lunch on 12/3/12, two (2) residents were observed with pureed meals with food white in color and lacking any accent color with the meal. Resident identifiers #6 and #15. b.) When Breakfast was served to Resident #1 on 12/4/12 it was all white and shades of beige. c.) The lunch meal received by Residents #1 and #9 on 12/4/12 was also white and shades of beige. d.) On 12/5/12 Resident #9 was served a lunch that was all white and lacked any accent color. e.) The appearance of the meals was discussed with the DON at 3:00 p.m. on 12/5/12. The Dietary Manager and the Dietician at 8:00 a.m. on 12/7/12.",2016-05-01
8629,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2012-12-07,428,D,0,1,L97I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and staff interview, the pharmacist failed to recognize and report drug irregularities for five (5) of eleven (11) sampled residents. Resident #2 had eight (8) as needed (prn) medications: [REDACTED]. In addition she had a prn order for Zofran four (4) milligrams (mg) which had not been administered for over sixty (60) days. There were no stop dates documented for these medications. Resident #6 was receiving the medication Digoxin 0.125 milligrams (mg) everyday for congestive heart failure. The facility policy states serum Digoxin levels are to be drawn every six (6) months. There were no orders or laboratory results in the medical records for a Digoxin level. Resident #5 had an order written [REDACTED]. According to the medication administration records (MAR) dated October 2012 and November 2012 this medication was never given and a stop date was not provided. In addition an order for [REDACTED]. Resident #16 had an order for [REDACTED]. Resident #3 was prescribed Seroquel twenty-five (25) milligrams (mg) twice a day on admission 02/22/12. Pharmacy first addressed this medication on 08/14/12 stating that it was appropriate for this resident and on 10/11/12 pharmacy recommended an attempt to taper the Seroquel dose. In addition the resident had incomplete as needed orders for Preperation H and Anusol creams. There was no specification as to when and where to apply which cream nor a stop date identified. Nystatin cream was ordered on [DATE] for an as needed basis but lacked a stop date and an indication for use. Resident identifiers: #2, #6, #5, #16, #3. Facility census: 16. Findings include: a) Resident #2 Review of the medical record on 12/06/12 revealed the following prn medications: [REDACTED]. Zofran 4 mg was administered once between 08/01/12 and 11/30/12 on 09/29/12 and currently remains on the residents MAR indicated [REDACTED] The pharmacy reconciliation notes dated 01/12/12 through 12/04/12 verifies the pharmacist failed to recognize and notify the physician to discontinue prn medications which were not used for 60 days as the facility policy states. A staff interview on 12/06/12 at 9:30 a.m. with the Director of Nursing (DON) employee #11 revealed the facility's routine is to automatically stop prn medications after thirty (30) days. She admitted they had not been following this policy and discontinuing the prn medications that were not being administered. The pharmacy Stop Orders policy received on 12/06/12 at 10:27 a.m. from the DON employee #11, states All new medication orders are subject to automatic stop orders unless the medication orders specify the number of doses or duration of medication. A time limit is included in recapped orders. All prn medication orders, except for nitroglycerin, are discontinued in 60 days if not utilized at all during that time, unless the prescriber specifically orders them to be continued indefinitely or for a special period of time. b) Resident #6 Medical record review on 12/05/12 at 10:30 a.m., revealed Resident #6 was ordered Digoxin 0.25 mg (milligrams) daily for congestive heart failure (CHF). A review of the monthly drug regime reviews conducted, by the consulting pharmacist, revealed no information regarding monitoring of the digoxin level for Resident #6. A previously provided copy of the facility policy titled Medication Monitoring was reviewed. Under the following section the policy states: 1. DIGOXIN ? A six months serum digoxin level is obtained, unless the physician orders [REDACTED]. On 12/06/12 at 3:00 p.m., a review of the physician orders [REDACTED]. The DON was asked if any evidence of a digoxin level being obtained could be produced. On 12/06/12 at 3:45 p.m., in an interview with the DON, revealed a digoxin level had last been completed on 04/04/11. She agreed the monitoring of a digoxin level had not been obtained for this resident in over a year. c.) Resident #5 A record review performed on 12/4/12 of physician's order [REDACTED]. No indication for usage was listed. The medication administration records (MARs) for October 2012 and November 2012 verify this medication was never administered during that time period and no stop date was provided. Another order dated 11/22/2010 for Tylenol 650 mg suppository was incomplete as it did not specify a route for administration. This information was discussed with the Director of Nursing (DON) on 12/5/12 at 2:30 p.m. and she was unable to provide further information. According to the facility policy titled Stop Orders , All PRN {as needed} orders, except for nitroglycerin, are discontinued in 60 days if not utilized at all during that time, unless the prescriber specifically orders them to be continued indefinitely or for a specified period of time. d.) Resident #16 A physician's orders [REDACTED].{per rectum} every 6 hours prn {as needed}. Nausea . This order was dated 8/4/12. I had not been administered during October or November, 2012. No stop date was listed. As per facility policy and procedure, all as needed medications not used in past 60 (sixty) days are to be discontinued. e.) Resident #3 Seroquel 25 mg twice a day was among the list of medications ordered for Resident #3 upon admission 2/22/12. It was not until 8/14/12 when Pharmacy first addressed Seroquel and stated it was still appropriate as Resident #3 was having hallucinations. On 10/11/12 pharmacy made a recommendation for the physician to try and taper the Seroquel. On 10/24/12 the physician completely discontinued the Seroquel. On 10/25 there was a physician's order [REDACTED]. This was discussed and verified with the Pharmacist on 12/4/12 at 4 p.m. In addition, Resident #3 had physician orders [REDACTED]. There is no order to specify under what situation the nurse should apply Preparation H and when to apply the Anusol. The Preparation H order is incomplete and does not include a site where to apply, nor does it have a stop date. The original order was written 9/9/2005. The Anusol order also does not have a stop date and is dated 4/1/2009. An order dated 3/1/11 stated Nystatin Cream to vaginal area and labia PRN {as needed} . This order has no stop date and gives no indication as to what symptoms constitute as needed . These orders were discussed with the DON on 12/5/12 at 2:30 p.m. and she had no further information. The policy clearly states that all as needed medications not used in sixty (60) days will be discontinued. According to the Medication Administration Record [REDACTED].",2016-05-01
8630,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2012-12-07,431,F,0,1,L97I11,"Based on observation and staff interview, the facility failed to label over-the-counter (OTC) medications with the opened date. Medications were found in a medication cart and the medication storage room were not dated as to when the medication had been opened. This has the potential to affect all residents receiving OTC's. Facility census: 16. Findings include: a) On 12/04/12 at 12:00 p.m., an observation was made, with the director of nursing (DON), of the medication room. A open bottle of ferrous sulfate was found with no date as to when the medication had been opened. The DON agreed the medication was not dated. She further agreed the facility policy was to date and initial any medication when it is initially opened. Inspection of the medication cart, conducted on 12/04/12 at 2:45 p.m., with a licensed practical nurse (LPN - Employee #4), revealed MiAcid (Mylanta), milk of magnesia (MOM), OsCal, and Allergra not dated as to when the medication had been opened. Employee #4 agreed the policy was to date and initial the medication when it was opened. On 12/05/12 at 8:30 a.m., Employee #4 was observed opening a new bottle of medication and proceeding to date and initial the new bottle.",2016-05-01
8631,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2012-12-07,441,F,0,1,L97I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and staff interview, the facility failed to follow sanitary infection control practices to prevent the contamination of medications. During the observation of a medication pass, a medication, dropped on the medication cart, administered to a resident. Furthermore, a nurse used fingers to remove medications from multiple bottles of over-the-counter medications. This affected two (2) of ten (10) residents observed during a medication pass. Resident identifiers: Resident #15 and #16. Facility census: 16. Findings included: a) Resident #15 On 12/05/12 at 8:50 a.m., observation of a licensed practical nurse (LPN - Employee #4), revealed an [MEDICATION NAME] tablet was dropped on the medication cart, picked up and placed in the medication cup. Furthermore, Employee #4 used her fingers to remove [MEDICATION NAME] sulfate and aspirin from the bottles of medication. This employee then proceeded to give the medications to Resident #15. b) Resident #16 On 12/05/12 at 8:27 a.m., observation of a licensed practical nurse (LPN - Employee #4), revealed this employee used her fingers to remove aspirin from the bottle. This employee then proceeded to give the medication to Resident #16. In an interview with Employee #4, on 12/05/12 at 9:15 a.m., revealed this employee agreed medications were not removed from medication bottles with fingers. This employee agreed the medication dropped on the medication cart were to be discarded. On 12/05/12 at 2:00 p.m., a review of the facility policy titled, Oral Medication Administration Procedure, revealed under section Key Points the following: 6. Pour the correct number of tablets or capsules into the medication cup. * Never touch any of the medications with fingers.",2016-05-01
8632,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2012-12-07,514,C,0,1,L97I11,"Based on record review, observation, and staff interview the facility failed to assure that a part of the medical record for all residents was readily accessable for resident care in accordance with accepted professional standards. This had the potential to effect all residents. Facility census 16. Findings include: a) During the initial interview with the Director of Nurses at 12:30 p.m. on 12/03/12, she informed this surveyor that all aspects of the record were available on the chart except the MDS which was in the computer and hard copies are no longer being produced for the chart. During a discussion of accessing the MDS on the morning of 12/05/12, with Employee #4 (Licensed Practical Nurse) she stated that she would have to request someone to do this as she did not have access to the computer. This was verified with the DON, who stated that only she, the unit clerk, and the MDS nurse have entry to the computer. When asked, she stated that they all worked day shift. She acknowledged that they had not considered the lack of access by the nursing staff caring for the resident when the decision was made not to print hard copies of the MDS for the chart.",2016-05-01
9161,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2013-02-13,280,D,1,0,1G6H11,"br>Based on medical record record review and staff interview, the facility failed to revise a care plan for one (1) of five (5) sampled residents, to include additional activities and/or services to ensure optimal quality of life. Resident identifier: #1. Facility census: 14. Findings include: a) Resident #1 Review of a social service's progress note, dated 09/14/12, revealed the Medical Power of Attorney (MPOA) had asked about hospice services. The MPOA's goals for hospice services were to ensure more people visited the resident because the MPOA was not able to visit often. A social services progress note, dated 10/12/12, revealed the MPOA had met with the facility care plan team. An agreement was reached to have increased visits from pastoral care and volunteers in lieu of Hospice, related to the MPOA only wanting Hospice for increased visits. The current care plan included interventions to increase 1:1 visits with staff and activities, as the resident enjoyed 1:1 visits and conversation. According to the current care plan, he enjoyed 1:1 making over him, smiles, laughs and loves extra attention. The current care plan made no mention of increased visits from pastors and volunteers, as previously decided in the October 2012 care plan meeting. During an interview with the licensed social service manager, on 02/13/13 at 9:45 a.m., she said that Resident #1 receives pastoral visits from two (2) to four (4) times each month. She said that he does not have an assigned volunteer, but when volunteers visit during the week, they will visit with him 1:1. During an interview with the MDS (Minimum Data Set) coordinator/registered nurse, Employee #18, and the consultant administrator, on 02/13/13 at 4:00 p.m., they agreed there was not a care plan to have extra pastoral visits and volunteer visits.",2016-02-01
9162,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2013-02-13,367,D,1,0,1G6H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and physician interview, the facility failed to follow physician's orders for a prescribed diet, or alternatively, to consult the physician regarding a need for a change in the resident's diet order for one (1) of five (5) sampled residents. Resident identifier: #1. Facility census: 14. Findings include: a) Resident #1 Observation of the morning meal, on 02/13/13 at 8:30 a.m., found Resident #1 being assisted with his meal which included french toast. He showed no visible signs at that time of choking, or difficulty swallowing. Observation of the noon meal, on 02/13/13 at 12:15 p.m., found a nursing assistant sitting by his side in the dining/activity room, assisting him with his meal. He was served a chicken salad sandwich that had been cut in half, as well as soup and some pureed food and Ensure. During an interview with a licensed nurse, Employee #14, on 02/13/13 at 12:30 p.m., she said Resident #1 was on a regular diet when he first arrived from an assisted living facility, but he would not eat well. He would pocket food in his cheek. He had no dentures and no natural teeth, and he could not chew all foods on a regular diet. He received a regular diet at breakfast with soft foods such as scrambled eggs and french toast or pancakes with syrup. She said he was served a soft sandwich at lunch and dinner daily. Sometimes he refused the sandwich, and at other times he ate nothing but the sandwich. He also received soft textured foods such as ice cream, pie without the hardened crust, cake, soft vegetables, soup, soft fruit such as bananas. She said the texture of the food served was in relation to his being edentulous. She said his food intake declined while on a regular diet, but increased when the texture was changed to pureed. She said he did not choke on foods to her knowledge. Review of a social service care plan note, dated 10/12/12, revealed the Medical Power of Attorney (MPOA) had concerns with pureed food, and the MPOA asked that he have a sandwich at lunch and dinner time. The registered dietitian agreed to try this, and send it along with his pureed food. The Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/31/12, was reviewed. It revealed his Brief Mental Assessment (BIM) score was only three (3) which signified severe cognitive loss. He was coded as having a swallowing/nutritional status problem with loss of liquids/solids from his mouth, coughing or choking. He was 74 inches tall, and weighed 119 pounds. A dietary progress note, dated 01/03/13, revealed the resident had a regular diet for breakfast and NDD1 (National Dysphagia Diet - a pureed diet) for lunch and dinner. In this note, the dietitian said the resident continued to have loss of liquid from the mouth, coughing and choking at meal times, and he was on a mechanically altered diet. Review of an Informed Refusal form, dated 01/25/13, revealed physical therapy, occupational therapy, and speech/language pathology had made a recommendation for a pureed diet for all meals. This was also recommended by the Interdisciplinary Team (IDT), but was refused by the MPOA. The purpose and benefit of those care or treatment recommendations was noted, as well as the risks of refusing them, and of possible alternatives. The current care plan was reviewed. It revealed the resident received a regular diet for breakfast and a NDD2 (National Dysphagia Diet - a mechanically altered diet) for lunch and dinner, and he coughed and choked at meals at times. Review of the current physician's orders revealed an order for [REDACTED]. During an interview with the MDS coordinator/registered nurse, Employee #18, and consultant administrator, Employee #22, on 02/13/13 at 4:00 p.m., they agreed there was not a physician's order for the sandwiches for lunch and dinner which the resident was receiving daily. During a telephone interview with the physician, on 02/13/12 at 4:30 p.m., he said he recalled the MPOA asking him if it would hurt the resident to have a sandwich once in awhile, to which he told her that it would not hurt him. He said he did not recall if nursing staff had requested sandwiches for the lunch and dinner meals, but said they probably did, and he would write an order to that effect. He said he did not recall anyone asking for regular diets for all meals.",2016-02-01
10495,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2011-01-06,225,D,0,1,CROM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of a fall investigation, policy review, and staff interview, the facility failed to immediately report an injury involving possible neglect, and failed to report the findings of a thorough investigation into the event within five (5) working days of the incident. On 11/18/10, one (1) of seven (7) sampled residents fell from a Hoyer lift when the sling became detached, sustaining a fracture that required surgical repair. The facility's immediately ruled out mechanical failure of the lift as the cause of the sling becoming detached from the device, but the facility failed to immediately report the incident as having resulted from possible neglect by the nurse aide involved; instead, the facility reported the event as an ""unusual occurrence"". The facility also failed to report the findings of an investigation into the incident to State officials as required within five (5) working days, although the facility implemented measures, such as requiring the assistance of two (2) staff members with all transfers via mechanical lift, following the occurrence of this incident. Resident identifier: #8. Facility census: 16. Findings include: a) Resident #8 A review of Resident #8's medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Review of an incident report for 11/18/10 revealed the resident had fallen while being transferred from a chair to her bed by a nurse aide using a Hoyer lift; the lift sling became unattached, and the resident fell and sustained a [MEDICAL CONDITION] femur requiring hospitalization and surgical repair. The facility recognized immediately there was no obvious malfunction of the lift, and they reported the incident to the State survey and certification agency as an ""unusual occurrence"". Having ruled out mechanical failure as the cause, the facility failed to identify and report the fall as having been the result of possible neglect by the nurse aide involved. In an interview with the facility's risk manager (who was in charge of the reporting process) at 10:40 a.m. on 01/04/11, she stated that an in-depth investigation had been done and was still part of a quality assurance root cause analysis that was not yet complete. She produced the documentation of the investigation and acknowledged that the facility immediately made procedural changes by posting the requirement that two (2) staff members be present for all mechanically assisted transfers (posted on 12/22/10). She stated that she would report the incident as soon as possible. During an interview with the nursing director of the unit at 9:30 a.m. on 01/05/11, she verified that the lift had been checked thoroughly for malfunction immediately after the incident, and nothing was mechanically wrong with the lift. It was pointed out to her that the facility's policy / procedure for using the lift stated: ""5. Check and verify proper sling attachment before starting the process."" ""10. The resident should be lifted slightly off a surface, and the lift paused, to check balance of the resident and the strap connections."" She agreed that, if these things had not been done, it would have been considered neglect and would have been reported as such, but she did not comment on actual findings of the investigation. .",2015-03-01
10496,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2011-01-06,241,D,0,1,CROM11,". Based on observations, staff interview, and record review, the facility did not ensure two (2) of seven (7) sampled residents received care in a manner that maintained or enhanced each resident's dignity and respect in full recognition of the resident's individuality. Resident identifiers: #3 and #61. Facility census: 16. Findings include: a) Residents #3 and #61 An observation, at 5:00 p.m. on 01/03/11, revealed food trays were placed in the room shared by Residents #3 and #61. The residents were observed sitting in bed with an overbed table and food tray in front of each resident. Residents #3 and #61 were observed sleeping at 5:30 p.m., and neither resident had not started to eat their food. At 5:45 p.m., both residents were again observed, and the director of nursing (DON - Employee #14) was in the room and was encouraging the residents to eat. The DON stated to the residents, ""The food is cold, and I will get you something else to eat."" The residents did not consume any of their food. An interview with the DON, on 01/03/11 at 5:45 p.m., revealed that someone should have gone into the residents' room and encouraged both of the residents to eat. Record review revealed Residents #3 and #61 did not have capacity and required supervision and staff assistance with meals. .",2015-03-01
10497,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2011-01-06,258,E,0,1,CROM11,". Based on observation and staff interview, the facility did not provide for the maintenance of comfortable sound levels in the facility's only dining room during meal service. Six (6) randomly observed residents were present during an observation of the evening meal at 5:30 p.m. on 01/03/11, which found residents yelling out and banging on surfaces. This had the potential to affect more than a minimal number of residents. Resident census: 16. Findings include: a) An observation of the facility's dining room, on 01/03/11 at 5:30 p.m., revealed six (6) residents eating dinner. Two (2) of the residents were yelling loudly, and one (1) of the two (2) was banging on the lap table. A resident was observed sitting between these two (2) residents making the loud sounds. A nurse aide asked the resident if she wanted to move to the other side of the dining room, and the resident continued to eat and shook her head to indicate ""no"". Three (3) residents were observed sitting on the other side of the dining room, and the loud sounds were also heard in this area. An interview on 01/04/11 at 2:00 p.m., the director of nursing (DON - Employee #14) acknowledged the dining room was small and reported that the residents who required total care with eating were brought in at the same time as other residents who may only require supervision or assistance. The dining room's noise level was usually high because of residents who were unable to control their behavior of yelling. .",2015-03-01
10498,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2011-01-06,279,D,0,1,CROM11,". Based on record review, family interview, observation, and staff interview, the facility failed to develop a comprehensive care plan that included measurable objectives and timetables to meet a resident's medical needs as identified in the comprehensive assessment for one (1) resident of seven (7) sampled residents. The resident had functional limitations in range of motion that were not address in the care plan. Resident identifier: #12. Facility census: 16. Findings include: a) Resident #12 A review of an assessment of Resident #12 for functional limitation in range of motion, dated 12/19/10, indicated, ""Impairment of both sides for upper extremity: shoulder, elbow, wrist and hand and impairment on both sides lower extremity: hip knee, ankle and foot."" A review of the resident's care plan did not address the resident's limited range of motion. An interview with the resident's daughter, on 01/04/11 at 10:00 a.m., revealed the family did not want a splint applied to the resident right's hand. Observation revealed the fingers of the resident's right hand were able to extend without difficulty, but the wrist was contracted and did not move. An interview with the director of nursing (DON - Employee #14), on 01/04/11 at 3:00 p.m., confirmed the resident's care plan did not address limitations in range of motion, but she felt they should take credit for doing passive range of motion for the resident. She further stated a care plan will be developed immediately to address the resident's limited range of motion. .",2015-03-01
10499,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2011-01-06,280,D,0,1,CROM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed, for one (1) of seven (7) residents reviewed, to review and revise the resident's care plan to assure conditions were accurately addressed, when the resident had experienced a significant weight loss and when the resident consistently refused to participate in a program of restorative nursing services that had been established by the therapy department. Resident identifier: #15. Facility census: 16. Findings include: a) Resident #15 1. When reviewed during the course of the annual re-survey event from 01/03/11 through 01/05/11, Resident #15's medical record was found to contain a note entered by the facility's consultant registered dietician (RD) dated 01/04/11, stating the resident had a ""33 pound weight loss since admission"". The resident was admitted to the facility on [DATE]. Review of the resident's vital signs and weight record revealed the following weights: - 147# on 09/27/10 - 141# on 10/01/10 - 124# on 11/04/10 - 119# on 12/02/10 - 115# on 01/04/11 This represented a loss of 32# in approximately three (3) months. Further review disclosed that, on 10/11/10, the facility received a physician's orders [REDACTED]. On 11/03/10, the facility had changed the resident's diet from regular consistency foods at all meals to pureed consistency foods for lunch and dinner and regular consistency foods at breakfast. The resident's comprehensive care plan, established on 10/11/10, identified as a problem: ""Leaves 25% of meals uneaten. Self feeding difficulty. Constant drooling-loss of liquids and food during mealtime."" It was also noted that the resident had ""Potential for dehydration"". The resident's care plan had not been revised to reflect the resident's current nutritional status or to reflect the steps taken (e.g., nutritional supplement and diet change) in an effort to reverse the weight loss. When the resident continued to lose weight after 11/03/10, the interdisciplinary team failed to develop or implement any additional measures in an effort to retard or reverse this unplanned weight loss. - 2. The resident's record, when further reviewed, disclosed a physical therapy daily note, dated 10/01/10, with directives to ""D/C to restorative program."" The restorative nursing program plans, as stated on the restorative nursing and progress summary form, stated: ""Ambulate on level surface with CAN (sic) and no loss of balance x 50 feet with rolling walker. Appropriate use of rolling walker during stand, pivot, transfer (sic). Exercise to improve function."" The care plan problem was noted to be: ""Decreased posture, decreased balance, decreased functional mobility. Recent decreased function / cognition. Dx (diagnosis): [MEDICAL CONDITION]."" Approaches included: ""Ambulate with rolling walker 250 feet with supervision. Promote good seated / standing posture, transfer with supervision."" Review of the restorative nursing and progress summary reports revealed that, after 11/07/10, the resident did not participate in the restorative program. As of 01/04/11, there had been no reassessment to determine why the resident was refusing to participate. The resident's care plan had noted the development of a restorative services plan on 10/01/10, but it had not been updated at any time since the resident began to refuse the services on 11/08/10. .",2015-03-01
10500,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2011-01-06,282,D,0,1,CROM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed, for one (1) of seven (7) residents reviewed, to provide services as established in his written plan of care. The resident was noted to be seated in a multi-positional wheelchair where he sat, during one (1) observation period, without re-positioning for long periods of time and, at another time, his feet were dangling unsupported several inches above the floor. His care plan indicated he was supposed to be positioned for comfort, and the unit's director of nursing (DON) acknowledged that his feet should have been supported by foot rests. Resident identifier: #15. Facility census: 16. Findings include: a) Resident #15 At the time of entrance to the facility on [DATE] at 1:30 p.m., observation found Resident #15 sitting in a wheelchair in the hall near the nurse's station. Although it appeared the back of the wheelchair was able to be reclined, the resident was observed in the upright position with his feet on the foot rests secured with some sort of band-like device. The resident was observed at numerous times during this afternoon by two (2) surveyors, and never was he observed to be in a different position. At approximately 5:30 p.m. on 01/03/11, the resident was moved to the common area where some residents took their meals. The resident remained in the same position. The resident, at this time, became agitated, reaching out for objects that were not there, etc. The resident's position was not changed throughout the meal, which ended at approximately 6:00 p.m. On 01/04/11 at 2:17 p.m., the resident was observed to be up in the same wheelchair in a slightly back-tilted position with his feet not secured on the foot rests and dangling approximately four (4) inches from the floor. - On 01/05/11 at 9:50 a.m., the DON (Employee #14), designated as being in charge of the unit, was interviewed. When asked about the resident's ability to move himself in the chair, Employee #14 stated he could not reposition himself. When told of the observations on 01/03/11 of the resident not being repositioned between 1:30 p.m. and 6:00 p.m., this employee stated that all residents were toileted at shift change, around 3:00 p.m., in preparation for dinner. She did not see this observe this having occurred for Resident #15 on 01/03/11; nor did the surveyors observe this to have occurred. Employee #14 also stated the resident's feet should not have been dangling unsupported but should have been positioned on the foot rests. When asked how this resident was supposed to be positioned, Employee #14 stated that Resident #15 was in a wheelchair that could be reclined and this would alternate areas of pressure; she also confirmed his feet should be positioned on the foot rests. - The resident's admission minimum data set assessment (MDS), dated [DATE], was reviewed and, although chair positioning was not directly addressed, the assessor encoded, in Section G0110 (Activities of Daily Living related to Bed Mobility) the resident as requiring the extensive assistance of two (2) or more persons for repositioning. The resident's care plan (dated 09/28/10) identified a problem of ""altered comfort"". Although the resident's inability to reposition himself was not directly addressed, the interdisciplinary team (IDT) determined the resident required the following interventions: ""positioned for comfort, encourage rest periods throughout the day depending on resident's activity level or [MEDICAL CONDITION], monitor lower extremities for [MEDICAL CONDITION] and elevate lower extremities if [MEDICAL CONDITION] is present."" In the area of resident's medical [DIAGNOSES REDACTED]. - At the time of exit from the facility on 01/05/11 at 1:45 p.m., facility staff could provide no evidence that staff was implementing the resident's care plan as determined necessary when it was established on 09/28/10. .",2015-03-01
10501,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2011-01-06,309,G,0,1,CROM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide care and services to one (1) of seven (7) sampled residents as determined necessary by his comprehensive assessment and plan of care to attain the highest practicable physical status. Resident #15 was admitted to the facility on [DATE], at which time he weighed 147 pounds (#). On 10/01/10, he weighed 141#, the physician ordered a nutritional supplement three (3) times daily for additional calories. On 11/03/10, the physician ordered changes to the consistency of his meals, serving pureed foods at lunch and dinner, and on 11/04/10, he weighed 124#. The resident continued to lose weight after 11/04/10, with no evidence of further assessments for the cause(s) of the unplanned weight loss and no further additional interventions implemented in an effort to slow or reverse the weight loss. By 01/04/11, he weighed 115#, which represented a 32# unplanned weight loss over a period of approximately three (3) months with no evidence to reflect this weight loss was clinically unavoidable. Additionally, on 10/01/10, the physician ordered restorative nursing services to improve his physical functioning. The resident refused to participate in the restorative nursing programs for two (2) months. A significant change in status assessment, with an assessment reference date of 01/04/11, revealed he had experienced a significant decline in self-performance of activities of daily living in at least five (5) areas since admission. There was no evidence of efforts by the facility's interdisciplinary team, prior to this survey event, to reassess or revise the resident's care plan to address the resident's refusal of participate in the restorative services intended to improve his physical functioning. Resident identifier: #15. Facility census: 16. Findings include: a) Resident #15 When reviewed on 01/04/11, Resident #15's medical record revealed this [AGE] year old male had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Record review revealed a note entered by the facility's consultant registered dietitian (RD), dated 01/04/11, stating the resident had a ""33 pound weight loss since admission"". Review of the resident's vital signs and weight record revealed the following weights: - 147# on 09/27/10 - 141# on 10/01/10 - 124# on 11/04/10 - 119# on 12/02/10 - 115# on 01/04/11 This represented a loss of 32# in approximately three (3) months. Further review disclosed that, on 10/11/10 (the date of the care plan review), the facility received a physician's orders [REDACTED]. Documentation on a ""Resident Nutritional Assessment"" revealed notations of the resident's weights and a note, dated 11/03/10, stating the resident's diet was changed from regular consistency foods at all meals to regular consistency foods for breakfast only and pureed consistency foods for lunch and dinner; the author also noted that the resident did not want nursing staff to feed him. There were no further entries in the record by dietary personnel until 01/04/11, when the RD noted the resident's weight loss, described meal intakes, medications, etc., and ended by saying ""resident is currently not meeting care plan goal of consuming 70% of meals or maintaining his weight."" The medical record revealed no evidence of further interventions related to this significant unplanned weight loss. - 2. A physical therapy daily note, dated 10/01/10, discontinued the resident from physical therapy to a restorative nursing program. The restorative nursing program plans stated: ""Ambulate on level surface with CAN (sic) and no loss of balance x 50 feet with rolling walker. Appropriate use of rolling walker during stand, pivot, transfer (sic). Exercise to improve function."" The care plan problem was noted to be: ""Decreased posture, decreased balance, decreased functional mobility. Recent decreased function / cognition. Dx (diagnosis): [MEDICAL CONDITION]."" Approaches included: ""Ambulate with rolling walker 250 feet with supervision. Promote good seated / standing posture, transfer with supervision."" Review of the restorative nursing and progress summary reports revealed that, after 11/07/10, the resident did not participate in the restorative program. As of 01/04/11, there had been no reassessment to determine why the resident was refusing to participate, nor was any revision made to the care plan in light of the resident's refusal of treatment. - 3. Review of the resident's admission assessment, with an assessment reference date (ARD) of 10/07/10, revealed in Section G the resident required supervision and set-up assistance with eating; the limited assistance of one (1) person for walking in the corridor, locomotion off the unit, and toilet use; the limited assistance of two or more persons with transfers; and the extensive physical assistance of two (2) or more persons with walking in the room. Review of a significant change in status assessment, with an ARD of 01/03/11, revealed in Section G the resident required the limited assistance of one (1) person with eating; the extensive physical assistance of two (2) or more persons for transfers and toilet use; the activity of walking in the room occurred only once or twice during the reference period and required the assistance of one (1) person; the activity of walking in the corridor did not occur at all during the reference period; the resident was totally dependent on one (1) person for locomotion off the unit. A comparison of these two (2) assessments revealed the resident had significant declines in self-performance in transfers, walking in room, walking in the corridor, locomotion off the unit; and toilet use in a three (3) month period. - 4. The director of nursing (DON - Employee #14), when interviewed on 01/04/11 at 4:14 p.m., confirmed that staff was aware of the resident's weight loss and that, other than the addition of the Mighty Shakes and a change of consistency of the resident's diet early in his stay, nothing else had been done. Employee #14 further stated the resident's medical power of attorney representative did not want aggressive treatment. This employee confirmed the resident had refused to participate in the physician-ordered restorative nursing services and that no reassessment or revision to the resident's care plan had occurred. - 5. At the time of survey team's exit from the facility at 1:15 p.m. on 01/05/11, facility staff had not provided evidence that the resident's significant unplanned weight loss had been discussed with him and/or his responsible party in an effort to assess for cause(s) of the loss and to develop and implement a plan to reverse the weight loss. .",2015-03-01
10502,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2011-01-06,314,G,0,1,CROM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of seven (7) residents reviewed who entered the facility without a pressure ulcer, to provide care and services to prevent the development of a pressure ulcer. When admitted to the facility on [DATE], Resident #15 had no pressure ulcers present and no history of having had resolved pressure sores. Facility staff failed to implement measures to assure the resident maintained good nutritional status, and the resident experienced a clinically avoidable 32 pound (#) weight loss in three (3) months at the facility. Physical therapy had developed a plan for restorative nursing care, in which the resident refused to participate for two (2) months with no re-assessment by staff. Staff interview confirmed Resident #15 had sustained a significant unplanned weight loss and that the resident's refusal to participate in restorative services could have contributed to the pressure ulcer development. The resident developed two (2) Stage II pressure ulcers with no evidence to indicate this skin breakdown was clinically unavoidable. Resident identifier: #15. Facility census: 16. Findings include: a) Resident #15 When reviewed on 01/04/11, Resident #15's medical record revealed this [AGE] year old male had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Documentation on the resident's comprehensive assessment, completed at the time of admission on 09/27/10 at 10:45 a.m., stated (in the area of skin assessment) the resident had a lesion on left upper eyelid, a bruise on his left forearm, a brown birthmark on his posterior right leg, and a skin tear on the anterior right lower leg. This document stated the resident, at that time, had no pressure ulcers and no history of resolved pressure ulcers. An initial care plan developed on 09/28/10 identified: ""Alteration in skin integrity (sic) episodes of incontinence and Hx (history) of acne / rash (sic) Currently on neck base of hair line."" The goal associated with this problem stated: ""Resident will have no skin breakdown through next review."" The interventions to assist the resident achieving this goal were: ""1) Assess skin every shift and observe for signs of reddness (sic). Charge nurse will notify physician for treatment orders. 2) Bactrim DS i (1) PO (by mouth) everyday - MPOA (medical power of attorney representative) states resident has history of pustules on face - resolved with maintenance dose of bactrim (sic). Currently has rash on neck - hair / collar line. Will observe for signs of healing or if treatment is needed. 3) Resident's functional ability to transfer and ambulate has declined over last several wks (weeks) - assist resident, but encourage functional activity, ROM (range of motion), exercise. Therapy to evaluate for restorative nursing program."" - According to the resident's comprehensive care plan dated 10/11/10, the interdisciplinary team (IDT) identified the following problem: ""History of acne / rash currently on neck base of hair line. At risk for skin breakdown due to decreased mobility, medication use, disease process. Fragile skin, bruises easily, Skin (sic) tear RFA (right forearm). Pressure ulcers (sic)."" (Note: According to documentation in the resident's record, the resident had no pressure ulcers at this time.) The goal related to this problem statement was: ""Resident will have no skin breakdown through next review."" The interventions to assist the resident in achieving this goal remained essentially the same as stated in the initial care plan, with the following additions: ""Braden skin assessment quarterly. Wound / pressure ucler (sic) record if indicated. RFA skin tear treatment: [MEDICATION NAME] (sic) dressing covered with opsite (sic). Change prn (as needed) discontinue when healed. Notify physician if there are signs of infection or poor healing. When sitting up, ensure that resident is sitting on foam cushion."" - Documentation recorded on forms titled ""Pressure Ulcer Record"" described the development of a Stage II pressure ulcer to his left heel on 11/17/10 and a Stage II pressure ulcer on his right buttock on 12/12/10. - Further record review disclosed that, on 10/11/10 (the date the resident's comprehensive care plan was established), the facility received a physician's orders [REDACTED]. On 11/03/10, the facility changed the resident's diet from regular consistency foods at all meals to pureed consistency foods for lunch and dinner and regular consistency foods at breakfast. Review of the resident's nutritional assessment disclosed that, by the time the first pressure ulcer developed on the resident's left heel, the resident had already experienced an unplanned weight loss of 13# from his admitting body weight of 147#. At that time, no new nutritional interventions were implemented to promote wound healing / skin integrity. Review of the resident's vital signs and weight record revealed the following weights: - 147# on 09/27/10 - 141# on 10/01/10 - 124# on 11/04/10 - 119# on 12/02/10 - 115# on 01/04/11 This represented a loss of 32# in approximately three (3) months. After 11/02/10, there were no further entries in the record by dietary personnel until 01/04/11, when the registered dietitian noted the resident's weight loss, described meal intakes, medications, etc., and ended by saying ""resident is currently not meeting care plan goal of consuming 70% of meals or maintaining his weight."" The medical record revealed no evidence of interventions (after 11/03/10) related to this significant unplanned weight loss or evidence of efforts to improve the resident's nutritional status as a means of promoting wound healing. - A physical therapy daily note, dated 10/01/10, discontinued the resident from physical therapy to a restorative nursing program. The restorative nursing program plans stated: ""Ambulate on level surface with CAN (sic) and no loss of balance x 50 feet with rolling walker. Appropriate use of rolling walker during stand, pivot, transfer (sic). Exercise to improve function."" The care plan problem was noted to be: ""Decreased posture, decreased balance, decreased functional mobility. Recent decreased function / cognition. Dx (diagnosis): [MEDICAL CONDITION]."" Approaches included: ""Ambulate with rolling walker 250 feet with supervision. Promote good seated / standing posture, transfer with supervision."" Review of the restorative nursing and progress summary reports revealed that, after 11/07/10, the resident did not participate in the restorative program. As of 01/04/11, there had been no reassessment to determine why the resident was refusing to participate, nor was any revision made to the care plan in light of the resident's refusal of treatment. - According to a Braden assessment of the resident's risk for developing pressure sores, completed on 10/03/10, the resident scored ""17"", indicating he was at ""mild risk"" for developing a pressure sore. According to a subsequent Braden assessment, completed on 01/03/11, the resident scored ""12"", indicating he was now at ""high risk"" for developing a pressure sore. - When interviewed on 01/04/11, the unit's director of nursing (DON - Employee #14) was not aware the resident had a pressure ulcer. Employee #14 confirmed Resident #15 had sustained a significant unplanned weight loss and that the resident's refusal to participate in restorative services could have contributed to the pressure ulcer development. .",2015-03-01
10503,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2011-01-06,323,D,0,1,CROM11,". Based on observation, staff interview, and record review, the facility failed, for one (1) of seven (7) residents reviewed, to assure each resident's environment was as free from accident hazards as possible, by restraining a cognitively impaired resident in an unsafe device and placing her in a room without staff supervision. Resident #4, whose assessment revealed she had severely impaired cognitive skills for daily decision making and an impaired ability to communicate, was seated in a geriatric chair with the tray table in place that prevented rising. There was sufficient space between the chair and the tray to allow the resident to scoot out of the chair, and the resident was placed in an area with other confused residents without staff present to monitor for safety. Resident identifier: #4. Facility census: 16. Findings include: a) Resident #4 Observation, during the initial tour of the facility on 01/02/11 at approximately 1:15 p.m., found Resident #4 sitting in a geriatric chair with a tray attached; the resident was located in the unit's activity / dining area with two (2) other residents. The tray, when in place, did not allow the resident to rise from the chair. The resident was not being fed, and no staff was present in the room. Further observation revealed that, due to the resident's small body size, there were several inches between her body and the tray. The resident was observed to remain in this chair, in almost constant motion, until approximately 2:30 p.m., when a nursing assistant assisted the resident from the chair to the bathroom. The resident was able to walk with staff assistance. The nursing assistant (Employee #1), when asked why the resident was in the chair, reported that it was to prevent her from ambulating independently. When asked, this nursing assistant agreed that it could be possible for the resident to slid from the chair under the tray. The unit's director of nursing (DON - Employee #14) was made aware of the resident's unsafe restraint and, at that time, the tray from the chair was removed and the chair was reclined. The resident's medical record, when reviewed on 01/04/11, disclosed the most recent minimum data set was dated as completed on 10/27/10. In Section B, the assessor noted the resident was sometimes understood by staff and sometimes able to understand staff. In Section C, the assessor noted the resident's cognitive skills for daily decision making was severely impaired - never / rarely makes decisions. This assessment would indicate the resident did not have the ability to remain safe in the unsafe device. .",2015-03-01
10504,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2011-01-06,325,G,0,1,CROM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide care and services, to one (1) of seven (7) sampled residents, to maintain acceptable parameters of nutritional status. Resident #15 was admitted to the facility on [DATE], at which time he weighed 147 pounds (#). On 10/01/10, he weighed 141#, and the physician ordered a nutritional supplement three (3) times daily for additional calories. On 11/03/10, the physician ordered changes to the consistency of his meals, serving pureed foods at lunch and dinner, and on 11/04/10, he weighed 124#. The resident continued to lose weight after 11/04/10, with no evidence of discussions with the resident or responsible party about the weight loss, no evidence of further assessments to identify possible reversible causes of the unplanned weight loss, and no evidence of further interventions implemented in an effort to slow or reverse the weight loss. By 01/04/11, he weighed 115#, which represented a 32# unplanned weight loss over a period of approximately three (3) months with no evidence to reflect this weight loss was clinically unavoidable. Resident identifier: #15. Facility census: 16. Findings include: a) Resident #15 When reviewed on 01/04/11, Resident #15's medical record revealed this [AGE] year old male had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a combined medical power of attorney and living will document dated 10/05/09, which identified his chosen representative and the following directives: ""no tube feeding, breathing machines, [MEDICAL TREATMENT], cardiopulmonary resuscitation."" Review of the resident's vital signs and weight record revealed that, on the date of admission (09/27/10), he weighed 147# with a height of 62 inches. According to his admission assessment with an assessment reference date (ARD) of 10/07/10, the assessor encoded in Section G that the resident required only supervision and set-up assistance with eating. According to the resident's initial comprehensive care plan (dated 10/11/10), the interdisciplinary team identified the following problem: ""Leaves 25% of meals uneaten. Self feeding difficulty. constant (sic) drooling - loss of liquids and food during mealtime. Nutrition (sic)."" At the bottom of this problem statement was: ""Potential for dehydration."" (This handwritten entry was not dated.) The goal related to this problem was: ""Resident will consume 70% of meals and maintain current weight plus or minus 5 pounds of baseline through next review."" Interventions to assist the resident in achieving this goal were: ""Will provide menu for resident and friend to complete and return to dietary weekly with resident' (sic) personal food preferences. Will check labs, weights and intakes as available. Will provide nutritional supplement 3x/day (three times daily) with meals. Nursing or friend will assist with feeding as needed. Resident will be provided with opportunity to drinks fluids throughout the day. Coffee / snack cart will provide between meals coffee and snacks twice daily."" As of 01/04/11, no additions or modifications had been made to this care plan since it was established on 10/11/10. - Review of the resident's record revealed a note entered by the facility's consultant registered dietitian (RD), dated 01/04/11, stating the resident had a ""33 pound weight loss since admission"". Review of the resident's vital signs and weight record revealed the following weights: - 147# on 09/27/10 - 141# on 10/01/10 - 124# on 11/04/10 - 119# on 12/02/10 - 115# on 01/04/11 This represented a loss of 32# in approximately three (3) months. Further review disclosed that, on 10/11/10 (the date the resident's comprehensive care plan was first established), the facility received a physician's orders [REDACTED]. Documentation on a ""Resident Nutritional Assessment"" revealed notation of the weights and a note, dated 11/03/10, stating the resident's diet was changed from regular consistency foods at all meals to regular consistency foods for breakfast only and pureed consistency foods for lunch and dinner; the author also noted that the resident did not want nursing staff to feed him. There were no further entries in the record by dietary personnel until 01/04/11, when the RD noted the resident's weight loss, described meal intakes, medications, etc., and ended by saying ""resident is currently not meeting care plan goal of consuming 70% of meals or maintaining his weight."" The medical record revealed no evidence of further interventions related to this significant unplanned weight loss. - When interviewed on 01/04/11 at 4:14 p.m., the unit's director of nursing (DON - Employee #14) confirmed that staff was aware of the weight loss; she also confirmed that, other than the interventions of the Mighty Shakes and a change in the consistency of foods served to the resident early in his stay, nothing else had been done to address the resident's weight loss. This employee further stated the resident's medical power of attorney representative did not want aggressive treatment. At the time of survey exit at 1:15 p.m. on 01/05/11, facility staff had not provided evidence that the resident's significant unplanned weight loss had been discussed with him and/or his responsible party, in an effort to identify possible reversible causes of the weight loss and/or additional interventions to retard or reverse the weight loss. .",2015-03-01
10505,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2011-01-06,329,D,0,1,CROM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to ensure the drug regimen, for one (1) resident of seven (7) sampled residents, was free of unnecessary drugs. Resident #7 had been receiving a nightly dose of [MEDICATION NAME] for [MEDICAL CONDITION] for months without any improvement in her difficulty sleeping, and there was no evidence to reflect the facility had identified the resident continued to receive this medication in the absence of therapeutic benefit. Resident identifier: #7. Facility census: 16. Findings include: a) Resident #7 Review of the resident's medical record found a physician order, dated 04/09/10, for [MEDICATION NAME] 1 mg at night, which had been reduced from a previous order to administer 2 mg. A review of nursing notes found the resident stayed awake at night during the months of August through December 2010; the resident was not sleeping at night even after receiving the dose of [MEDICATION NAME]. An interview with a nurse (Employee #21), on 01/05/11 at 10:00 a.m., revealed the resident was getting worse, wanting to sleep during the day time and not at night. Observation, on 01/03/10 at 3:00 p.m., found the resident sitting in a geri-chair in front of the nursing station sleeping. On 01/04/10 at 11:00 a.m., 2:00 p.m. and 4:00 p.m., observations found the resident sleeping. An interview with the director of nursing (DON - Employee #14), on 01/05/11 at 11:00 a.m., revealed the order for [MEDICATION NAME] would be discontinued. She further stated, ""The [MEDICATION NAME] has not been working for the resident for months and needs to be discontinued."" .",2015-03-01
10506,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2011-01-06,371,F,0,1,CROM11,". Based on observation and staff interview, the facility did not ensure food was stored, prepared, and/or served under sanitary conditions. This had the potential to affect all sixteen (16) residents of the facility, as all received foods prepared from this central location. Facility census: 16. Findings include: a) An observation made in the nutritional pantry on the nursing unit, on 01/03/11 at 3:00 p.m., revealed an open bottle of liquid in the pantry refrigerator that did not have a label specifying the contents of the bottle or a date to indicate when the bottle was placed in the refrigerator. In an interview on 01/03/11 at 3:00 p.m., the director of nursing (DON - Employee #14) stated the bottle of liquid should be discarded, and she was observed pouring the liquid from the bottle down the drain in sink. - b) Observation, on 01/03/11 at 4:30 p.m., found the holding temperature for cole slaw that had been plated for service to residents was 50 degrees Fahrenheit (F). The cole slaw, a potentially hazardous food that needed to be held at or below 41 degrees F, was intended to be delivered to ten (10) residents. The cook (Employee #25) placed the cole slaw in the refrigerator for thirty (30) minutes and took the temperature again. The temperature remained at 50 degrees F. The registered dietitian (RD - Employee #24) then directed dietary personnel to substitute the cole slaw with green beans. An interview with the RD, on 01/03/11 at 5:00 p.m., revealed the cole slaw could not be served to the residents at a 50 degree F. - c) An observation, on 01/03/11 at 4:30 p.m., revealed a large container in the refrigerator with a label indicating the date ""12/16/10"". Employee #25 indicated they never keep the sour cream on the shelf that long. - d) An observation, on 01/03/11 at 4:30 p.m., found two (2) dietary staff (Employees #26 and #25) with their hair not completely covered. The hair coverings were setting on the backs of their heads, exposing all of their hair in the front. .",2015-03-01
10507,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2011-01-06,428,D,0,1,CROM11,". Based on observation, record review, and staff interview, the facility failed to ensure an irregularity in the drug regimen of one (1) of seven (7) sampled residents was identified or addressed by the consultant pharmacist. Resident #7 had been receiving a nightly dose of Lunesta for insomnia for months without any improvement in her difficulty sleeping, and there was no evidence to reflect the consultant pharmacist had identified the resident continued to receive this medication in the absence of therapeutic benefit. Resident identifier: #7. Facility census: 16. Findings include: a) Resident #7 Review of the resident's medical record found a physician order, dated 04/09/10, for Lunesta 1 mg at night, which had been reduced from a previous order to administer 2 mg. A review of nursing notes found the resident stayed awake at night during the months of August through December 2010; the resident was not sleeping at night even after receiving the dose of Lunesta. An interview with a nurse (Employee #21), on 01/05/11 at 10:00 a.m., revealed the resident was getting worse, wanting to sleep during the day time and not at night. She further stated the resident started to stay up all night beginning in August 2010. Observation, on 01/03/10 at 3:00 p.m., found the resident sitting in a geri-chair in front of the nursing station sleeping. On 01/04/10 at 11:00 a.m., 2:00 p.m. and 4:00 p.m., observations found the resident sleeping. An interview with the director of nursing (DON - Employee #14), on 01/05/11 at 11:00 a.m., revealed the order for Lunesta would be discontinued. She further stated, ""The Lunesta has not been working for the resident for months and needs to be discontinued."" A review of resident's drug regimen reviews, completed by the facility's consultant pharmacist for the months of May through December 2010, found no mention of any irregularities related to the use of the Lunesta. .",2015-03-01
10508,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2011-01-06,465,D,0,1,CROM11,". Based on observation and staff interview, the facility did not ensure that geri-chairs were functional and able to be effectively sanitized between uses by different residents. The arm rests of two (2) of five (5) geri-chairs had tears in the fabric, exposing padding beneath the fabric, which rendered these surfaces unable to be sanitized between uses. Facility census: 16 Findings include: a) Observation, on 01/03/11 at 4:30 p.m., found two (2) geri chairs located in the dining room with tears in the fabric covering the arm rests which exposed the padding beneath the fabric. The torn areas affected the entire arms of each geri chair and rendered their surfaces unable to be sanitized between uses. In an interview on 01/05/11 at 1:30 p.m., the director of nursing (Employee #14) acknowledged these geri chairs needed to be repaired.",2015-03-01
6948,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,164,D,0,1,WVZU11,"Based on a random observation, review of facility policies, and staff interview, the facility failed to provide personal privacy for a medical treatment. A resident received a breathing treatment in the dining room. The treatment continued into the serving and eating of lunch. Resident identifier: #22. Facility census: 59. Findings include: a) Resident #22 During the initial tour of the facility, shortly after entrance at 11:30 a.m. on 06/17/13, Resident #22 was observed in the dining room by two (2) surveyors. He was reclined in a geri-chair and had on oxygen (O2). A staff member approached him and initiated a nebulizer treatment in front of numerous other residents who were awaiting lunch, including a resident who was sitting at Resident #22's table. This treatment was still taking place as lunch was served and as the other resident at the table was served his lunch. On 06/20/12 at 10:10 a.m., the DON was interviewed about breathing treatments. She said it should not happen during meals and it was a daily occurrence. An interview was attempted with Resident #22 on 06/20/13 at 10:30 a.m. He was cognitively unable to complete the interview. A second interview with the DON was held on 06/24/13. She discussed giving nebulizers in dining room and said it was a dignity issue. She provided the facility's medication administration policy which did not include information about giving medications in public. A policy and procedure on aerosol treatments was provided by the Director of Respiratory Therapy at 3:30 on 06/24/13. It did not include information about giving treatments in public areas. The facility practice was discussed and he said they have been doing it for a couple of years, not for the therapist's convenience, but for the resident. He felt it decreased confusion by not dragging residents back to their rooms for a treatment, and then dragging them back. He did not acknowledge a violation of privacy by giving breathing treatments in public.",2017-09-01
6949,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,279,D,0,1,WVZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to develop an individualized care plan for a resident receiving as needed (PRN) anti-anxiety medication and for a resident who developed a pressure ulcer. Two (2) of twenty-three (23) residents whose care plans were reviewed during Stage 2 were affected. The care plan for Resident #65 did not identify specific behaviors to be monitored and did not identify non-pharmacological interventions to be attempted prior to the administration of PRN [MEDICATION NAME]. The care plan for Resident #38 did not identify measurable goals and objectives when this resident developed a pressure ulcer on the left ankle. Resident identifiers: #65 and #38. Facility census: 59. Findings include: a) Resident #65 On 06/19/13 at 12:28 p.m., a review of the physician's orders [REDACTED]. An additional order stated, [MEDICATION NAME] 0.5 MG PRN Q4H. Route: ORAL. Additionally in an E-SIGN PROCESS NOTE, signed by the physician on 04/03/13 at 15:58 (3:58 p.m.), under PLAN 11. Continue p.r.n. medicines . [MEDICATION NAME] IM or p.o. for extreme agitation and restlessness. The care plan, which was initiated on 04/09/13, revealed a problem statement which included the resident had the potential for drug-related complications related to [MEDICATION NAME]. The goal stated, The resident will not develop drug-related complications through review date. The interventions did not include specific behaviors to be monitored or non-pharmacological interventions to be attempted, prior to the administration of the PRN [MEDICATION NAME]. The care plan interventions were, Reduce drug dosage, if possible, administer medications as ordered by physician, encourage adequate fluid intake with meals, with medications, on room visits and with hydration pass at 6a, 2p, and 8p, assess anxiety level, cause of anxiety and develop coping mechanism, provide emotional and spiritual support as needed, pharmacist and [MEDICAL CONDITION] committee review of medication regime, notify medical doctor of recommendations, and [MEDICATION NAME]: monitor for changes in LOC (level of consciousness), caution in elderly, renal (kidney) and hepatic (liver) disorders, monitor for physical dependency after long term use and notify medical doctor of any problems.' These interventions were not individualized to reflect specific behaviors to monitor or non-pharmacological interventions, e.g., offering fluids/food, toileting, positioning, redirection, etc. to be attempted prior to giving the [MEDICATION NAME]. In an interview with the director of nursing (DON), on 06/24/13 at 1:50 p.m., she agreed the care plan should contain non-pharmacological interventions such as trying food and fluids, toileting, and getting the resident out of bed. In addition, the DON agreed there were no specific behaviors identified in the care plan for the staff to monitor for as an indication to administer the [MEDICATION NAME]. b) Resident #38 A Stage 1 staff interview, on 06/18/13, identified Resident #38 had a pressure ulcer on his left ankle. Review of the medical record also identified a healed pressure ulcer on the right ankle. Review of the care plan, on 06/24/13 at 9:30 a.m., revealed no indication of a pressure ulcer, current or resolved. All sections of the care plan were reviewed. Employee #178, the director of nursing (DON), reviewed the care plan on 06/24/13 at 12:30 p.m. She confirmed there was no indication of a pressure area to the left ankle. She also reviewed the initial problem list/care plan, and confirmed it did not identify the infected left ankle wound as a pressure area. Additionally, Resident #38 had pressure area to the right ankle, which had resolved on 04/25/13. A history of pressure ulcers was not identified as a risk factor for the potential for impaired skin integrity.",2017-09-01
6950,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,323,K,0,1,WVZU11,"Based on observations, resident comment, and staff interview, the facility failed to provide an environment free from accident hazards. A resident (Resident #67) was observed to touch a metal heating unit in a room designated for dining on the second floor long term care unit and immediately withdraw his hand. When measured, the temperature on the top surface of this unit was 135 degrees Fahrenheit. The temperature in the area where heat was expelled was measured to be 200 degrees Fahrenheit. This area of the unit was also accessible to anyone who might decide to touch it. The unit was midway down the surface of the wall, immediately below the window, at the level accessible without requiring the resident to bend over. This practice had the potential to affect all residents residing on the 2nd floor long term care unit and rendered the mobile, self-ambulatory residents to be in immediate jeopardy of being burned on the unit. The administrator was advised of the immediate jeopardy at 11:18 a.m. on 06/18/2013. The administrator immediately turned the unit off and had the maintenance department disable the unit. The unit and other like units were subsequently removed from the walls. The immediate jeopardy was removed at 2:25 p.m. on 06/18/2013 and no deficient practice remained relative to the heating units. Census on this unit was 17. However, environmental safety issues were also identified that had a potential for more than minimal harm, but not actual harm or immediate jeopardy. A can of disinfectant deodorizer was left where it was accessible to residents, hand rails had areas that could cause injury to residents, and water temperatures were found to be in ranges above those safe for bathing and which could result in burns with exposure of three (3) to five (5) minutes. Facility census: 59. Findings include: a) While conducting a random tour of the 2nd floor long term care unit of the facility on 06/18/13 at 11:05 a.m., Resident #67 was wheeling about the unit and requested the surveyor look at the plants in the window in the room designated for dining. Upon approaching the window and plants, a heating unit was noted to be emitting heat directly under the window. The resident stated that won't be on , and touched the unit. The resident immediately withdrew his hand and said hot. The resident was encouraged to leave the room to maintain his safety, with questioning him about other areas of the unit. The temperature on the upper surface of the metal unit was then measured and determined to be 135 degrees. The temperature of the area where the heating was actually exiting the unit, also accessible to residents, was measured to be 200 degrees. These observations were made by two (2) surveyors. The facility Administrator was asked to come to the dining room. Upon his arrival in the dining room, the temperatures were again measured by the surveyors while he observed. Temperature measurements at that time were noted to be 135 degrees on the top surface and 199 degrees in the area of heat expulsion. The facility administrator was advised the excessive surface temperatures of the heating unit constituted a risk of immediate jeopardy to facility residents at 11:18 a.m. on 06/18/2013. The Administrator immediately turned off the heating unit and called maintenance staff to disable the unit, temporarily removing the chance of harm to residents, until a plan for correction could be established and implemented. At 2:15 p.m. on 06/18/2013 the facility Administrator presented a plan of correction which included completely removing the wall heater units, repairing and fixing the walls. At 2:25 p.m. the heaters were determined to have been removed from the walls, walls had been repaired and were ready to be painted. The immediate jeopardy was removed at 2:25 p.m. on 06/18/2013 and no deficient practice remained. b) During a Stage 1 observation, on 06/18/13 at 8:49 a.m., an aerosol can was seen on the shelf above the sink, in room 039 on Unit 1. The sink was located to the left when entering the doorway. Employee #89, a nursing assistant (NA), said it was a disinfectant deodorizer. She said it belonged to the facility's housekeeping department, and acknowledged it was not supposed to be there. The director of nursing (DON) was interviewed on 06/18/13. She confirmed the deodorizer should not have been left in resident's room. c) A check of the water temperatures at hand sinks, on 06/20/13 at 10:50 a.m., located in the following resident rooms, found hot water temperatures as follows: Room 32 - 124.0 degrees F Room 33 - 123.0 degrees F Room 34 - 123.8 degrees F Room 31 - 123.9 degrees F Room 36 - 123.3 degrees F Room 27 - 122.4 degrees F Room 40 - 122.6 degrees F Room 41 - 122.0 degrees F Room 1 - 121.1 degrees F Room 3 - 121.1 degrees F Room 5 - 120.4 degrees F Room 8 - 120.5 degrees F Room 9 - 120.3 degrees F These temperatures were obtained by the maintenance supervisor, Employee #77, with a facility thermometer. While taking these temperatures, Employee #77 stated he was aware the temperatures should be 110 degrees. On 6/20/13 at 11:25 a.m., water temperatures at residents' sinks on nursing facility Unit 2 were obtained by Employee #77 using the facility's thermometer. The findings were as follows: Room 214 - 111.7 degrees F Room 215 - 119.0 degrees F Room 217 - 117.3 degrees F Information in the Guidance to Surveyors for this requirement, found in Appendix PP of the CMS State Operations Manual, revealed the following: Water Temp - Time required for a 3rd Degree Burn to Occur 155 degrees F - 1 seconds 148 degrees F - 2 seconds 133 degrees F - 15 seconds 127 degrees F - 1 minute 124 degrees F - 3 minutes 120 degrees F - 5 minutes 110 degrees - Safe Temperature for Bathing (See Note) Note: Burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. On 06/24/13 beginning at 10:45 a.m., water temperatures at residents' sinks were again obtained by Employee #77 with a facility thermometer. Water temperatures of the following rooms on nursing Unit 1 were obtained. Room 32 - 113.6 degrees F Room 33 - 113.6 degrees F Room 31 - 115.3 degrees F Room 34 - 113.2 degrees F Room 36 - 113.0 degrees F Room 27 - 112.2 degrees F Room 40 - 112.0 degrees F Room 41 - 111.5 degrees F Room 1 - 111.5 degrees F Room 3 - 111.3 degrees F Resident sink temperatures on nursing Unit 2 were all within required limits. Employee #77 stated he was working on adjusting the water temperatures. On 06/25/13 at 11:30 a.m., Employee #77 presented records of facility water temperatures. Employee #77 stated the facility did not record water temperatures in resident rooms. d) On 06/24/13 at 9:00 a.m., nursing Unit 2's handrails were observed with corner miter cuts that were no secured in place. Unsecured miter cuts were noted between resident room 214 and the elevator and between the nursing desk and staff restroom. Both of these areas were accessible to residents. Both of these unsecured miter cuts create a potential for a splinter, pinch, or skin tear. The condition of these hand rails had the potential to affect more than an isolated number of residents who used the handrails during ambulation. On 06/24/13 at 11:30 a.m., while touring nursing Unit 2, Employee #77 was shown the handrails of concern. The handrail between resident room 214 and the elevator had been repaired. The handrail between the nursing desk and staff restroom remained in disrepair. Employee #77 observed and acknowledged both mentioned areas of the handrails, but did not make a comment.",2017-09-01
6951,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,329,D,0,1,WVZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview with the medical director, and staff interview, the facility failed to ensure residents drug regimens were free of unnecessary drugs. This was found for two (2) of eleven (11) residents reviewed for unnecessary medications. Resident #65 received [MEDICATION NAME] on an as needed (PRN) basis without sufficient identification of the behaviors to be monitored or evidence of behavioral interventions. Resident #18 received [MEDICATION NAME] (an antipsychotic medication and [MEDICATION NAME] (an antidepressant medication), without a gradual dosage reduction. Resident #18 also did not have laboratory testing as recommended by the pharmacist, to monitor the use of [MEDICATION NAME] (an anticonvulsant). The facility also failed to inform the resident/responsible party of the benefits/risks of medications. Resident identifiers: #65 and #18. Facility census: 59. Findings include: a) Resident #65 On 06/24/13 at 1:30 p.m., a review of the medical record was conducted. The physician's orders [REDACTED].#65 had been ordered [MEDICATION NAME] 0.5 mg orally or IM (intramuscular) every four (4) hours as needed (PRN) with no [DIAGNOSES REDACTED]. In a physician's progress note, dated 04/03/13 at 15:58 (3:58 p.m.), in the section PLAN, it was noted Continue p.r.n. medicines . [MEDICATION NAME] IM or p.o. (by mouth) for extreme agitation and restlessness. The Medication Administration Record [REDACTED]. The Psychoactive Drug Monthly Flow Record, dated April 2013 in Section I Specific Behaviors indicated the monitoring of refusing care, increased agitation and aggression. The flow record documented no behaviors or side effects from 04/10/13 through 04/15/13. The days prior to this documentation and the days following were blank. A further review of Resident #65's MARs noted the following: On 03/28/13 at 8:26 a.m., [MEDICATION NAME] 0.5 mg was administered orally for anxiety. No evidence was discovered as to the reason the medication was given. There was no indication what constituted anxiety and how this was affecting the resident. On 03/30/13 at 13:35 (1:35 p.m.), [MEDICATION NAME] 0.5 mg was administered orally for other. The Patient Progress Notes indicated at 14:22 (2:22 p.m.), Disruptive Behavior: Going into other residents' room and going through their drawers. When tried to redirect, Resident became resistant with leaving room. Resident then began taking drinks off tray in hallway and started dumping them. When tried to take Ensure (nutritional supplement) that she spilled, became combative. Gave PRN [MEDICATION NAME] at 1325 (1:25 p.m.) No further evidence was discovered of other non-pharmacological interventions. On 04/01/13 at 18:22 (6:22 p.m.), [MEDICATION NAME] 0.5 mg was administered orally for agitation. A review of the patient progress notes during this time frame did not reveal any documentation as to why the [MEDICATION NAME] was given and any associated resident behaviors. Again, at 22:27 (10:27 p.m.) Resident #65 was given [MEDICATION NAME] 0.5 mg orally for anxiety. A review of the patient progress notes for 04/01/13 at 22:28 (10:28 p.m.) revealed the following nurse's note, medicated with PRN [MEDICATION NAME] 0.5 mg for increased anxiety; nursing interventions unsuccessful; will monitor. The nurses' notes provided no further description of the resident behaviors or the type of nursing interventions that were provided. On 04/05/13 at 8:15 a.m., [MEDICATION NAME] 0.5 mg administered orally for anxiety. The nurse's notes at 15:39 (3:39 p.m.) stated, Resident resting in bed at this time. This a.m., resident was sitting in hallway and started crying. Unable to tell staff what was wrong, just said 'I don't know why I'm crying.' [MEDICATION NAME] given as per PRN order. Thirty minutes later resident was no longer anxious. No anger outbursts. (Family member) called and updated on care and spoke with resident also. No non-pharmacological interventions were noted prior to administering [MEDICATION NAME]. 04/06/13 at 22:36 (10:36 p.m.)., [MEDICATION NAME] 0.5 mg administered orally for anxiety. The patient progress notes stated (typed as typed in the electronic medical record (EMR) Disruptive behavior: acting out verbally; yelling about reindeer; unable to calm down with nursing nursing interventions; medicated with PRN [MEDICATION NAME] 0.5mg; will monitor for success. An additional nurse's note, on 04/06/13 at 16:28 (4:28 p.m.) noted (typed as typed in the EMR) Resident has been up in chair most of day. - appitite remains good. Started hollaring out for her parents . 'they're probably out running around with the wrong people.' Then started hollaring for her 'no good boys of mine'. Started to get aggitated. [MEDICATION NAME] given per prn order. Resident sitting out in hall at present . There was no indication what nursing interventions were tried with this resident. On 04/07/13 at 13:09 (1:09 p.m.) and at 17:43 (5:43 p.m.), [MEDICATION NAME] 0.5 mg administered orally for anxiety. The nurse's note, at 15:07 (3:07 p.m.) stated (typed as typed into EMR) yelling for 'HELP', confused, and anxious. Given PRN [MEDICATION NAME]. There was no indication whether non-pharmacological interventions were attempted prior to giving the [MEDICATION NAME]. In the Controlled Medication Utilization Record, for Resident #65, an additional dose of [MEDICATION NAME] was noted on 04/07/13 at 1300 (1:00 p.m.). The MAR indicated [REDACTED]. There was no evidence in the nurses' notes to indicate the reason for giving the [MEDICATION NAME]. An interview with the director of nursing (DON) was conducted on 06/24/13 1:50 p.m The DON was asked if non-pharmacological interventions were to be tried prior to the administration of the PRN [MEDICATION NAME]. The DON responded Yes. Staff need to try food and fluids, toileting, and getting out of bed. After the DON reviewed the evidence in the patient progress notes and nurses' notes, she agreed no specific (non-pharmacological) interventions were consistently documented. The DON agreed there were times when there was no documentation of why the [MEDICATION NAME] had been given to Resident #65. When asked about the use of the monthly behavior monitoring forms, the DON explained the forms were implemented during a complaint survey in April 2013 because evidence could not be found of the documentation of behaviors and a reason for the administration of a PRN anti-anxiety meds. The DON confirmed the information was lacking regarding non-pharmacological nursing interventions that were attempted and the lack of specific behaviors as is required for the monitoring of unnecessary medications. b) Resident #18 1) During a Stage 1 observation, on 06/19/13 at 8:30 a.m., Resident #18 was observed walking from the dining room to her room, which was located at the end of the hallway. She had a shuffling, unsteady gait, and tremor of her hands. She utilized the handrails to stabilize herself while walking. During a medical record review for unnecessary medications, on 06/19/13 at 12:36 p.m., it was noted the resident received [MEDICATION NAME] and [MEDICATION NAME], which are [MEDICAL CONDITION] medications. The pharmacy recommendations were reviewed, and revealed the pharmacist had made recommendations which had been declined by the physician. A clinical rationale, specific to the resident, was not provided. Review of the behavior monitoring sheets indicated the resident had not been exhibiting the behaviors identified as indicators for receiving the medication. The pharmacist also noted the resident had not been exhibiting behaviors and had recommended gradual dose reductions. Pharmacy recommendations were noted as follows: On 11/13/12, the pharmacist had recommended a gradual dose reduction of [MEDICATION NAME] due to an increase of tremors, but there was no evidence of hallucinations or paranoia. The physician declined with the rationale the medication was working. However, a gradual dose reduction had been initiated on 01/18/12, and was successful. Also noted on the 01/18/12 recommendation, the physician's response for accepting the recommendation was, You know, I didn't start this drug in the first place, I don't think. A pharmacy review, completed on 07/25/12, indicated the resident was receiving [MEDICATION NAME] and [MEDICATION NAME]. The pharmacy recommendation noted the resident had a [DIAGNOSES REDACTED]. It noted [MEDICATION NAME] may antagonize [MEDICATION NAME]'s effects in the treatment of [REDACTED]. If continued, a risk versus benefits, indicating it continued to be a valid therapeutic intervention for Resident #18, needed to be completed. The physician declined the recommendation, noting the medications were ordered by a neurologist. Employee #98 a licensed practical nurse (LPN), who reviewed pharmacy recommendations and ensured compliance, and Employee # 94, a registered nurse (RN) and nurse manager of the long term care unit, were interviewed on 06/20/13 at 8:50 a.m. They confirmed a risk versus benefits had not been completed. They also confirmed the resident had not seen the neurologist for further intervention. Another interview with Employee #98 (LPN), on 06/20/13 at 11:20 a.m., revealed the facility did not communicate risk/benefits of medications to residents, mdedical powers of attorney, or surrogates. The LPN said the pharmacist told her they did not complete the task either. During another interview with Employee #98, on 06/20/13 at 1:20 p.m., she confirmed risks and benefits were not reviewed with the Resident #18, or her family, verbally or in writing Another pharmacy recommendation, dated 06/22/13, revealed a recommendation to decrease the [MEDICATION NAME], and noted an annual review was due. Resident #18's most recent minimum data set (MDS) indicated minimal depression symptoms. The physician declined the recommendation noting a reduction may impair the individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder. The physician's rationale to substantiate his concern was noted as Again. 2) A pharmacy recommendation for Serum [MEDICATION NAME] and [MEDICATION NAME] concentrations was initiated on 03/14/13. The rationale was a manufacturer's recommendation because [MEDICATION NAME] is actively metabolized to [MEDICATION NAME]. The physician's declination for obtaining labs was noted as, I didn't start her on this. During an interview with Employee #98 (LPN) and Employee #94 (RN/nurse manager), they confirmed the laboratory tests had not been completed. The physician failed to provide a clinical rational, specific to Resident #18, for the continuation of [MEDICATION NAME] or [MEDICATION NAME]. The physician also failed to provide a clinical rationale related to the declination of laboratory serum (blood) drug levels related to medications. A review of the pharmacy regimen review, revealed no recommendations related to [MEDICATION NAME], or [MEDICATION NAME], between November 2012 and June 2013. An interview with the medical director, Employee #269, on 06/24/13 at 7:50 a.m., revealed [MEDICAL CONDITION] medications are reviewed monthly. He said recommendations were made for gradual dose reductions every three (3) months. He indicated the process was recently initiated. The medical director reviewed the pharmacy recommendations for Resident #18. He confirmed sound clinical rationale was not provided. Employee #269 said he had addressed pharmacy recommendations in physician staff meetings. The medical director said he knew it was a concern, but was not aware of the specific responses made by the physician.",2017-09-01
6952,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,371,F,0,1,WVZU11,"Based on observation, staff interview, and policy review, the facility failed to ensure food was stored, prepared and distributed under sanitary conditions. Pots/pans were not adequately air dried to prevent moisture from being trapped inside of the item. This created a potential for the growth of microorganisms. A dietary staff member was observed handling a food item with her bare hand. Milk that had been poured into glasses in preparation of meal service, was not maintained at proper temperature. Temperatures of the refrigerators in the pantry area were not monitored in accordance with facility policy. In addition, items were not dated to indicate when they had been opened and/or by when they should be discarded. This had the potential to affect all residents who consumed food orally. Facility census: 59 a) Kitchen During an initial tour, on 06/17/13 at 1:30 p.m., pots were observed stored on top of each other in the sink area. Droplets of water were visible on the outside of them. A second tour, on 06/17/13 at 2:30 p.m., with Employee #192, a registered dietitian (RD) and the dietary supervisor, revealed the pots were still stacked on top of each other. When the RD removed the pots from each other, a large amount of condensation was observed between them. She said the pots should not have been stacked together and would need to be rewashed. An interview and observation with Employee #184, a nutrition service aide, on 06/20/13 at 2:20 p.m., revealed metal loaf-type pans were stacked together on a shelf near the sink. When she removed the pans, condensation was observed beneath them. Another interview with the RD, at 2:25 p.m. on 06/20/13, revealed all dishes were to air dry. The dietary supervisor removed the loaf-type pans from each other and noted water beneath each one. Employee #184 joined the conversation regarding why the dishes were stacked to dry. The RD said, no, it is not okay. She further added the dishes had to be rewashed and placed them back in the sink. Review of the dietetics, nutrition and food service department policy and procedure manual for sanitation/safety, Procedure No: 3105, on 06/20/13 at 4:00 p.m., revealed all items were to be air dried, then placed in proper storage areas. In addition, during an observation of the lunch tray line, on 06/18/13 at 11:25 a.m., Employee #188 (a cook) was putting food onto the plates. She had no glove on her right hand. She picked up the green leafy garnish and placed it on the plate with her ungloved hand. Employee #192 said the cook should have worn gloves. According to the dietary services policy, food should be served with suitable instruments so as to avoid manual contact with unpackaged foods. During the tray line observation, nine (9) glasses of milk (identified by Employee #192) were observed on a cart, with no means of keeping them chilled. The RD said they had been placed there prior to starting tray line. She removed a glass from the cart and checked the temperature. It was 50 degrees. She said the milk was too warm, and removed the cups from the cart. According to the dietary services policy, dairy products should be stored between 36 and 41 degrees. b). During the initial tour, which began at 11:30 a.m. on 06/17/13, the NCF 1 Pantry was inspected. The temperature logs for both the Coke Fridge and the Kitchen Fridge were incomplete. The policy for monitoring the temperatures of the refrigerators, dated 03/12/12, was reviewed on 06/20/13 and included, Nursing will record refrigerator/freezer temperatures twice daily. Inside the Kitchen Fridge was an open container of Nectar orange juice. The container was dated in black marker 09/6/12. The manufacturer's stamp said best used by 03/22/13. Employee #107, a nursing assistant (NA), was interviewed at 11:40 a.m. on 06/17/13. She said she did not know how or why the liquids in the refrigerators were dated. During a discussion with the director of nursing (DON), at 11:50 a.m. on 06/17/13, she said dietary would have to provide information about liquids and how long the dates were good. During a second interview with the DON on 06/18/13 at 2:00 p.m., she stated she had spoken with the dietitian who informed her the dates on the jugs in the refrigerator indicated when the products arrived at the facility. The DON continued to say that nursing was supposed to label the dates of the juice to indicate when it was opened/when it needed discarded, but she saw no labels by nursing on the juices in the pantry kitchen. A copy of the kitchen stocking schedule was obtained on 06/20/13 from the DON. The schedule noted dietary was responsible for rotating stock and removing discarded items in kitchen areas. In an interview with the Dietitian, at 10:00 am on 06/20/13, she confirmed the policy stating dietary was responsible removing outdated items from refrigerators and that the nectar orange juice, with a manufacturer's date best used by 03/22/13 should not have been in the refrigerator. Inspection of the refrigerator on 06/20/13 at 10:30 a.m., found the Nectar orange juice was no longer in the Kitchen Fridge.",2017-09-01
6953,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,428,D,0,1,WVZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to act upon pharmacy recommendations which identified medication irregularities for one (1) of eleven (11) residents reviewed for unnecessary medications. The physician failed to provide a clinical rationale when the pharmacist made recommendations. Resident identifier: #18. Facility census: 59. Findings included: a) Resident #18 1) During a medical record review for unnecessary medications, on 06/19/13 at 12:36 p.m., it was noted the pharmacist had made recommendations which had been declined by the physician. A clinical rationale was not provided. Review of the behavior monitoring sheets indicated the resident had not been exhibiting identified behaviors related to psychotropic medications. The pharmacy recommendations, also indicated the resident had not been exhibiting behaviors and had recommended gradual dose reductions. Pharmacy recommendations were noted as follows: On 11/13/12, the pharmacist had recommended a gradual dose reduction of Risperdal due to the resident having an increase of tremors, but no evidence of hallucinations or paranoia. The physician declined with the rationale the medication was working. However, a gradual dose reduction had been initiated on 01/18/12, and was successful. At that time, the physician's response for accepting the recommendation was, You know, I didn't start this drug in the first place, I don't think. A pharmacy review, completed on 07/25/12, indicated the resident was receiving Cogentin and Risperdal. It noted the resident had a [DIAGNOSES REDACTED]. It noted Risperdal may antagonize levodopa's effects in the treatment of [REDACTED]. If continued a risk versus benefits, indicating it continued to be a valid therapeutic intervention for Resident #18, needed to be completed. The physician declined the recommendation noting the medications were ordered by a neurologist. Employee #98 a licensed practical nurse (LPN), who reviewed pharmacy recommendations and ensured compliance, and Employee # 94, a registered nurse (RN) and nurse manager of the long term care unit, were interviewed on 06/20/13 at 8:50 a.m. They revealed a risk versus benefits had not been completed. They also confirmed the resident had not seen the neurologist for further intervention. Another interview with Employee #98 (LPN), on 06/20/13 at 11:20 a.m., revealed the facility did not communicate risk/benefits of medications to residents, medical powers of attorney or surrogates. The LPN said the pharmacist told her the pharmacy did not complete the task either. During another interview with Employee #98, on 06/20/13 at 1:20 p.m. she confirmed risks and benefits were not reviewed with Resident #18, or her family, verbally or in writing 2) Another pharmacy recommendation, dated 06/22/13, revealed a recommendation to decrease Zoloft, and noted an annual review was due. Resident #18's most recent minimum data set (MDS) had indicated minimal depression symptoms. The physician declined the recommendation noting a reduction might impair the individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder. The physician's rationale to substantiate his concern was noted as Again. A pharmacy recommendation for serum Primidone and Phenobarbital concentrations was initiated on 03/14/13. The rationale was a manufacturer's recommendation because Primidone is actively metabolized to Phenobarbital. The physician's declination for obtaining labs was noted as, I didn't start her on this. During an interview with Employee #98 (LPN) and Employee #94 (RN/nurse manager), they confirmed the laboratory tests had not been completed. The physician failed to provide clinical rational, specific to Resident #18, for the continuation of Risperdal or Zoloft. The physician also failed to provide clinical rationale related to the declination of laboratory serum (blood) drug levels related to medications. A review of the pharmacy regimen review, revealed no recommendations related to Risperdal, Zoloft, or Primidone, between November 2013 and June 2013. An interview with the medical director, Employee #269, on 05/23/13 at 7:50 a.m., revealed psychotropic medications were reviewed monthly. He said recommendations were made for gradual dose reductions every three (3) months. He indicated the process was recently initiated. The medical director reviewed the pharmacy recommendations for Resident #18. He confirmed sound clinical rationale was not provided. Employee #269 said he had addressed pharmacy recommendations in physician staff meeting. He said he knew it was a concern, but was not aware of the specific responses made by the physician.",2017-09-01
6954,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,431,E,0,1,WVZU11,"Based on observations and staff interview, the facility failed to ensure safe medication storage in a medication preparation cart. A medication cart was left unlocked and not visible to attending staff, providing an opportunity for unauthorized access. Facility census: 59 Findings Include: a) On 06/24/13 at 8:20 a.m., an observation on nursing unit two revealed an unattended and unlocked medication cart sitting next to the nursing station. Employee #170 walked out of a resident room, went to the medication cart still sitting next to the nursing desk and stepped away, leaving the cart out of her line of sight. She went into another resident room and returned to the cart. Employee #170 then obtained medications and again went into a resident room leaving the medication cart unlocked and not visible to her. When Employee #170 returned to the medication cart, it was brought to her attention the cart had been left unlocked and not visible to her. Employee #170 stated Usually I have it with me at the door. On 06/24/13 at 8:40 a.m., the director of nursing, referring to Employee #170 leaving the medication unlocked, stated, She did everything, but lock her cart and we can't stress that enough.",2017-09-01
6955,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,441,E,0,1,WVZU11,"Based on observation, staff interview, and policy review, the facility failed to store resident care equipment, and person hygiene items, in a manner to prevent the spread of infection. In addition, oxygen concentrators in the dining room were observed to be unclean. There was no method established to ensure humidification and tubing were changed when necessary. These practices had the potential to affect more than a limited number of residents. Resident identifiers: #18, #39, #12, #64, and #3. Facility census: 59. Findings included: a) Resident #18 During a Stage 1 observation, on 06/19/13 at 8:20 a.m., a urinary hat (used to collect urine specimens) was observed on the bathroom floor. An interview and observation with Employee #101, a licensed practical nurse (LPN), acknowledged storing the hat on the bathroom floor posed a potential for infection and cross contamination. b) Resident #39 On 06/18/13 at 10:06 a.m., an observation revealed a urine hat stored in a bedpan, which was stored on the floor under the commode. Additionally a urine graduate was stored on the back of the commode seat. An observation on 06/19/13 at 10:01 a.m., revealed the items were stored in the same manner. The director of nursing confirmed the graduate was soiled with urine. She said the items were not to be stored in the bathroom, and posed a source of infection and cross contamination. In addition, personal hygiene items, which included toothpaste, a toothbrush, and a denture cup, were stored on the shelf above the sink. The items were unlabeled. A container of mouthwash was stored without a lid. The director of nursing (DON) said she was unable to identify to whom the items belonged. She acknowledged they were stored in an unsanitary manner and posed a potential for cross contamination. c) Resident #12 A Stage 1 observation, on 06/19/13 at 8:49 a.m., revealed a bedpan stored on the bathroom floor. Employee #101 (LPN) looked in the bathroom and said, I'll take care of this. She said the bedpan was not to be stored in the bathroom. Additionally, personal hygiene supplies were stored on a shelf above the sink. Employee #89, a restorative aide, confirmed the items were unlabeled and said she did not know to whom they belonged. d) Resident #64 During a Stage 1 observation, on 06/18/13 at 9:32 a.m., a bedpan was observed stored on the floor of the bathroom. A second observation, on 06/19/13 at 9:56 a.m., revealed the bedpan was still on the floor. The DON agreed it should not be stored there. e) Resident #3 A urine hat was stored in a bedpan on the bathroom floor, under the commode, during a Stage 1 observation on 06/18/13 at 10:06 a.m. Another observation on 06/19/13 at 10:01 a.m., revealed the items were still on the floor. The DON acknowledged they were not stored in a sanitary manner and posed a source of infection and cross contamination. f) An interview with Employee #157, a nursing assistant, on 06/24/13 at 10:13 a.m., revealed the bedpans, urinals, urine graduates and hats were to be cleaned and placed in the bottom drawer of the bedside stand. She said she was told they were to be thrown away if found on the bathroom floor. During another interview with the DON, she said the bedpans were cleaned by being rinsed and then put in the nightstand. Review of the policy for administering a bedpan, it noted the bedpan was to be cleaned and stored after use. g) During a tour of the facility, on 06/17/13, two (2) oxygen concentrators were observed in the Unit 2 dining room, located on the second floor. An interview with Employee #97, a registered nurse (RN), revealed the oxygen was stored in the dining room with the humidification attached so that any resident who needed it could use it during activities, or while in the dining room. When questioned how the concentrator was maintained, the nurse said respiratory therapy cleaned the machine and replaced oxygen supplies (nasal cannula, humidification). The respiratory therapy director, Employee #242, and another respiratory therapist, Employee #243, were interviewed on 06/24/13 at 1:20 p.m. The director said the concentrators were checked every day and cleaned if soiled. Employee #242 said she removed the humidification if present. She and the director were unaware the humidification was present. The respiratory therapist said she did not date or initial the tubing when changed. When asked how she would know if a concentrator was missed during the change out, she said, I can't. She agreed a system was not in place to ensure all equipment was maintained according to the facility policy. The concentrators were observed on 06/17/13, 06/18/13, 06/19/13, 06/20/13, and 06/24/13. During each observation, the concentrators were stored in the dining room, with the humidification attached. On 06/24/13, Employee #242, a respiratory therapist (RT), looked at the concentrators. She said one belonged to the hospital, and hospice was responsible for the other concentrator. The one belonging to the facility had long streaks of a brown substance down the side of the concentrator. When she removed the humidification, brown and white crusty debris was visible. The RT agreed the machine was dirty and cleaned it at that time.",2017-09-01
6956,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,456,E,0,1,WVZU11,"Based on observation and staff interview, the facility failed to ensure kitchen equipment was maintained in a safe operating condition. This had the potential to affect all dietary staff. Facility census: 59. Findings included: a) During a tour of the kitchen, on 06/18/13, at 1:30 p.m., with Employee #192, (dietary supervisor), observation revealed a knob to the stove was missing, and the stove door had a cloth in the side of the door. A note on the front of the door indicated it was out of order. The dietary supervisor said maintenance had to fix the stove door. She said it needed a spring to stay shut because it flies open. She also said a line inside of the oven needed replaced. The dietary supervisor said she replaced the missing knob for the burner. Further observation revealed the floor of the walk-in freezer was covered with ice. Employee #192 said the door needed to be replaced, because it did not seal properly. She said temperatures were taken twice daily to ensure proper temperatures were maintained.",2017-09-01
6957,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,469,E,0,1,WVZU11,"Based on observation and staff interview, the facility failed to maintain a pest free environment. The dining room/solarium on nursing unit one was found to have numerous dead gnats trapped in cobwebs behind the blinds and found to have living gnats under a cloth placed on the floor and against the windows which extended to the bottom of the floor. Insects were also found in a resident's room. Facility census: 59 Findings Include: a) Upon entry to the facility, and initial observation of the dining room/solarium, a cloth was observed to have been placed on the floor and up against the window. On the second day of the survey, 06/18/13 at 11:45 a.m., the same cloth was again observed on the dining room/solarium floor. The cloth was picked up off of the floor and revealed living gnats under the cloth. Also noted were cobwebs behind the blinds with numerous gnats in the cobwebs. On 06/18/13 at 2:28 p.m., the maintenance supervisor, Employee #77 was interviewed in the dining room/solarium on nursing unit one. He acknowledged there were numerous cobwebs with insects trapped in them on the blinds, baseboard electric heaters, and rolled up towels that were placed against the heaters and at the bottom of the windows. He said the cloths were placed there to prevent water from flowing onto the floor when it rained, but the staff did not always remember to remove them. The cloths were observed to be partially stuck to the floor. (Employee #77 stated the circuit breakers for the floor heaters were turned off. The circuit breakers were observed in the off position.) b) During a Stage 1 observation on 06/18/13 at 9:22 a.m., gnats, too numerous to count, were observed in the residents' windows. One live gray insect was on the inside window sill. The unit charge nurse confirmed the presence of insects. She stated she would notify housekeeping. Observations on 06/24/13 at 3:15 p.m., revealed dead gnats, other dead bugs which looked like spiders, and beetles were present in the window. Bugs were noted in the heater unit also. Employee #101, a licensed practical nurse verified the presence of the bugs. She said she would notify housekeeping.",2017-09-01
6958,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,490,F,0,1,WVZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations, record reviews, review of personnel files, review of the State of West Virginia Hospital Licensure, Code 64CSR12, and staff interviews, it was determined the facility was not being administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Multiple systems related concerns were found. Issues were identified with the electronic medical record program used by the facility. Environmental issues were identified, including a situation that posed an immediate jeopardy to the ambulatory residents on the second floor nursing facility unit not being recognized by the facility. The facility did not have a system in place to monitor hot water temperatures in residents' rooms, did not have effective systems to ensure residents were free of unnecessary medications and that pharmacist's recommendations were acted upon. The facility did not ensure kitchen equipment was maintained in a safe operating manner or that the facility was free of pests. The facility also did not have a system in place to ensure nurse aides were registered and that nurse aides were provided with twelve (12) hours of in-service education annually as required. Also, the facility did not have a dedicated long term care administrator other than the hospital administrator as required by State of West Virginia Hospital Licensure, Code 64CSR12). These systemic problems had the potential to result in harm to more than a minimal number of residents. Facility census: 59 Findings include: a) The facility did not have a dedicated long term care administrator other than the full time hospital administrator as required by State of West Virginia Hospital Licensure, Code 64CSR12. b) Multiple, continuing environmental concerns were identified during the survey, including the existence of a situation that represented immediate jeopardy for [MEDICAL CONDITION] the residents on the second floor nursing unit that was not recognized by the facility until it was pointed out by the survey team. Additional environmental safety issues were also identified. A can of spray disinfectant deodorizer was left in a resident's room where it could be accessed by cognitively impaired residents. Water temperatures in resident rooms were found to be hot enough to [MEDICAL CONDITION] a resident be exposed for three (3) to five (5) minutes. On 06/20/13 at 10:50 a.m. the following temperatures were measured by Employee #77: room [ROOM NUMBER] - 124.0 degrees F room [ROOM NUMBER] - 123.0 degrees F room [ROOM NUMBER] - 123.8 degrees F room [ROOM NUMBER] - 123.9 degrees F room [ROOM NUMBER] - 123.3 degrees F room [ROOM NUMBER] - 122.4 degrees F room [ROOM NUMBER] - 122.6 degrees F room [ROOM NUMBER] - 122.0 degrees F room [ROOM NUMBER] - 121.1 degrees F room [ROOM NUMBER] - 121.1 degrees F room [ROOM NUMBER] - 120.4 degrees F room [ROOM NUMBER] - 120.5 degrees F room [ROOM NUMBER] - 120.3 degrees F On 06/20/13 at 11:25 a.m. the following temperatures were measured by Employee #77: room [ROOM NUMBER] - 111.7 degrees F room [ROOM NUMBER] - 119.0 degrees F room [ROOM NUMBER] - 117.3 degrees F On 06/25/13 at 11:30 a.m., Employee #77 presented records of facility water temperatures. Employee #77 stated the facility did not record water temperatures in resident rooms. c) During the survey, it was discovered that the facility's electronic medical record (EMR) software was not compliant with current accepted standards and practices regarding appropriate restrictions for staff access to protected health information (PHI) depending upon their job classification. The policy and procedure for the design and use of the system did not recognize and address this issue. d) The facility did not have an effective system in place to ensure residents were free from unnecessary medications. Two (2) of eleven (11) residents reviewed for unnecessary medications were found to not have gradual dose reductions, monitoring of targeted behaviors, monitoring of laboratory tests, and/or a nonpharmacologic interventions identified and implemented in an attempt to reduce the use of psychopharmacologic agents. Resident #65 received [MEDICATION NAME] on an as needed (PRN) basis without sufficient identification of the behaviors to be monitored or evidence of behavioral interventions. Resident #18 received [MEDICATION NAME] (an antipsychotic medication and [MEDICATION NAME] (an antidepressant medication), without a gradual dosage reduction. Resident #18 also did not have laboratory testing as recommended by the pharmacist, to monitor the use of [MEDICATION NAME] (an anticonvulsant). The facility also failed to inform the resident/responsible party of the benefits/risks of medications. e) The facility did not have a system in place to ensure recommendations made by the pharmacist were acted upon. On 11/13/12, the pharmacist had made recommendations for a dose reduction of [MEDICATION NAME] as the resident was having increased tremors and had no hallucinations or paranoia. The physician's response for accepting the recommendation was, You know, I didn't start this drug in the first place, I don't think. A pharmacy review, completed on 07/25/12, indicated the resident was receiving [MEDICATION NAME] and [MEDICATION NAME]. It noted the resident had a [DIAGNOSES REDACTED]. It noted [MEDICATION NAME] may antagonize [MEDICATION NAME]'s effects in the treatment of [REDACTED]. If continued a risk versus benefits, indicating it continued to be a valid therapeutic intervention for Resident #18, needed to be completed. The physician declined the recommendation noting the medications were ordered by a neurologist. Employee #98 a licensed practical nurse (LPN), who reviewed pharmacy recommendations and ensured compliance, and Employee # 94, a registered nurse (RN) and nurse manager of the long term care unit, were interviewed on 06/20/13 at 8:50 a.m. They revealed a risk versus benefits had not been completed. They also confirmed the resident had not seen the neurologist for further intervention. Another pharmacy recommendation, dated 06/22/13, revealed a recommendation to decrease [MEDICATION NAME], and noted an annual review was due. Resident #18's most recent minimum data set (MDS) had indicated minimal depression symptoms. The physician declined the recommendation noting a reduction might impair the individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder. The physician's rationale to substantiate his concern was noted as Again. A pharmacy recommendation for serum [MEDICATION NAME] and [MEDICATION NAME] concentrations was initiated on 03/14/13. The rationale was a manufacturer's recommendation because [MEDICATION NAME] is actively metabolized to [MEDICATION NAME]. The physician's declination for obtaining labs was noted as, I didn't start her on this. During an interview with Employee #98 (LPN) and Employee #94 (RN/nurse manager), they confirmed the laboratory tests had not been completed. The physician failed to provide clinical rational, specific to Resident #18, for the continuation of [MEDICATION NAME] or [MEDICATION NAME]. The physician also failed to provide clinical rationale related to the declination of laboratory serum (blood) drug levels related to medications. f) The facility failed to ensure kitchen equipment was maintained in a safe operating condition. During a tour of the kitchen, on 06/18/13, at 1:30 p.m., with Employee #192, (dietary supervisor), observation revealed a knob to the stove was missing, and the stove door had a cloth in the side of the door. A note on the front of the door indicated it was out of order. The dietary supervisor said maintenance had to fix the stove door. She said it needed a spring to stay shut because it flies open. She also said a line inside of the oven needed replaced. The dietary supervisor said she replaced the missing knob for the burner. Further observation revealed the floor of the walk-in freezer was covered with ice. Employee #192 said the door needed to be replaced, because it did not seal properly. She said temperatures were taken twice daily to ensure proper temperatures were maintained. g) Observations and staff interview identified the facility had failed to maintain a pest free environment. The dining room/solarium on nursing Unit 1 was found to have numerous dead gnats trapped in cobwebs behind the blinds and found to have living gnats under a cloth placed on the floor and against the windows which extended to the bottom of the floor. Insects were also found in a resident's room. h) Review of personnel files and staff interview found the facility had failed to obtain registry verification for one (1) of fourteen (14) employees (Employee #116) indicating she was a registered long term care nursing assistant before allowing her to serve as a nurse aide. i) Review of training records and staff interview identified the facility had failed to provide regular in-service education sufficient to ensure the continuing competence of nurse aides (NA), with a minimum of twelve (12) hours per year. This was found for five (5) of five (5) NA files reviewed. Employee identifiers: #103, #104, #107, #109, and #111.",2017-09-01
6959,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,492,F,0,1,WVZU11,"Based upon record review and staff interview, the facility failed to comply with with State of West Virginia Hospital Licensure, Code 64CSR12, which requires that the governing authority appoint a full time hospital administrator and that if there is a nursing facility unit with more than sixty (60) resident beds, the governing body shall also appoint a qualified administrator who holds a current valid license or emergency permit issued by the West Virginia Nursing Home Administrator's Licensing Board. This had the potential to result in harm to more than a minimal number of residents. Facility census: 59. Findings include: a) Review of entrance documents and interview with acting administrator, employee #3, on 6/20/13 at 4:00 p.m. found that he was acting as both the full time hospital administrator and as the administrator of the seventy-six (76) bed long term care unit under an emergency permit. He said that the former long term care administrator had quit on 4/19/13, and the position had been vacant for the last two (2) months. He said the vacancy had been advertised, and some applications received, but no applicants had been interviewed or considered. State of West Virginia Hospital Licensure, Code 64CSR12 requires that the governing authority appoint a full time hospital administrator and that if there is a nursing facility unit with more than sixty (60) resident beds, the governing body shall also appoint a qualified administrator who holds a current valid license or emergency permit issued by the West Virginia Nursing Home Administrator's Licensing Board. The hospital administrator voiced understanding that Hospital licensure rules prohibit him from serving in both positions concurrently.",2017-09-01
6960,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,496,B,0,1,WVZU11,"Based on record review and staff interview, the facility failed to obtain registry verification for one (1) of fourteen (14) employees indicating she was a registered long term care nursing assistant before allowing her to serve as a nurse aide. Employee identifier: #116. Census: 59. Findings include: a) Employee #116 Personnel records for fourteen (14) employees were requested and reviewed on 06/19/13 and 06/24/13. The file of a nursing assistant, Employee #116, contained no evidence she was a registered long term care nursing assistant. During an interview, on 06/20/13 at 11:00 a.m., nursing home administrative consultant, Employee #176, confirmed the required checks were not available. She provided a verification of active registration for NA #116 that had been obtained by the facility on 06/20/13 at 7:48 a.m. About an hour later, a certificate stating that NA #116 had successfully passed the West Virginia Nursing Assistant Written and Skills Performance Examination on 04/14/12 was provided. Employee #176 acknowledged that this documentation had not been maintained as part of the official personnel file.",2017-09-01
6961,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,497,E,0,1,WVZU11,"Based on record review and staff interview, the facility failed to provide regular in-service education sufficient to ensure the continuing competence of nurse aides (NA), with a minimum of twelve (12) hours per year. This was found for five (5) of five (5) NA files reviewed. Employee identifiers: #103, #104, #107, #109, and #111. Facility census: 59. Findings include: a) Employees #103, #104, #107, #109, and #111 Personnel files were requested and reviewed for these nurse aides on 06/24/13 at 1:30 p.m. The review of the records found no evidence indicating the NAs received the annual required minimum of twelve (12) hours of in-service education to ensure their continuing competence. On 06/24/13 at 2:45 p.m., the administrative assistant, Employee #6, provided a copy of the annual in-service power point called Annual Required Education Day (A.R.E.D.) which all staff were to attend. The education included infection control, fire safety and disaster, resident privacy, rights and dignity, and abuse. She verified this mandatory training did not add up to 12 hours of in-service education. During an interview with the director of nursing, Employee #178, and the long term care administrative assistant, Employee #177, on 06/24/13 at 4:00 p.m., they confirmed they do not count the NAs yearly education hours. The facility does not have a policy indicating the number of hours or type of education required annually by the nursing assistants to maintain competency and they could not verify any of the nursing assistants had received the required minimum number of twelve (12) hours of in-service training to maintain their competencies.",2017-09-01
6962,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,514,C,0,1,WVZU11,"Based on record review and staff interview, the facility failed to ensure the accuracy of the medical record by recording that weights were measured on a certain date when, in fact, there was no evidence of the exact date the resident was weighed. This was true for all thirty-two (32) residents in the Stage 1 sample. Resident identifiers: #1, #3, #5, #7, #10, #12, #14, #18, #20, #21, #23, #24, #25, #27, #28, #31, #34, #35, #38, #39, #40, #41, #42, #43, #48, #49, #53, #59, #63, #64, #65, and #66. Facility census: 59. Findings include: a) Residents #1, #3, #5, #7, #10, #12, #14, #18, #20, #21, #23, #24, #25, #27, #28, #31, #34, #35, #38, #39, #40, #41, #42, #43, #48, #49, #53, #59, #63, #64, #65, and #66. While reviewing the medical record for required resident weights, at 10:00 a.m. on 06/18/13, it was revealed that the weight books located at the nurses' station contained only the month and year, although when the medical record was accessed, an exact date was entered for the weights. The nurse on duty (Employee #125) was interviewed at 10:30 a.m. on 06/18/13. She verified that when the residents were weighed by the aides, the weights were documented in the weight book and that only the month and year were entered. She stated that all weights are done on the 1st of the month. When she was shown on the computer that there were different days indicated on different residents, she was surprised and had no answer. During an interview with Employee #162 (aide) at 10:50 a.m. on 06/18/13, she stated that residents were weighed between the 1st and the 5th of each month and verified they are not required to enter the day of the month when they record the weight. When interviewed at 9:00 a.m. on 06/20/13, the Director of Nurses (Employee #178) stated that weights were supposed to be taken during the last week of each month. After reviewing both the Weight Book and the computer record, she admitted that there was no way to tell which day the weight was taken. She had no explanation for the source of the entry date used in the computer record. In an interview with Employee #192 (dietitian) at 9:30 a.m. on 06/20/13, she affirmed that the date was important in calculating the percentage of weight gain or loss for each resident.",2017-09-01
6963,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,516,F,0,1,WVZU11,"Based on record review, policy review, observation, and staff interview the facility failed to maintain the safety and confidentiality of the residents' medical record by using an electronic medical record that does not have built-in safeguards to prevent unauthorized access of information in the medical record; and by having no written policies at the health care facility describing the attestation policies in force at the facility. This had the potential to affect all residents residing in the facility. Facility census 59. Findings include: The American Health Information Management Association (AHIMA) is the worldwide professional association of recognized leaders in health information management, informatics, heath data technology, and innovation. AHIMA proactively promotes the technological advancement of health information systems that enhance the delivery of quality healthcare. AHIMA recognizes that quality health and clinical data are critical resources needed for efficacious healthcare and works to assure that the health information used in care, research, and health management is valid, accurate, complete, trustworthy, and timely. Health issues, disease, and care quality transcend national borders. AHIMA's professional interest is in the application of best health information management practices wherever they are needed. AHIMA: LTC Health Information Practice and Documentation Guidelines ? Part of the facility policies on confidentiality should be an access grid that outlines which employees and contractors are considered authorized users of the medical record and any restrictions or limitations on what can be accessed. The grid should identify the authorized user by department and position and the limitations on access to information. If subcontractors are used for certain services (billing service, laundry, dietary, etc.), language needs to be included in the contracts outlining the employee's responsibility to maintain resident confidentiality and their authority to access the medical record. a) During the record review portion of the survey, observations were made of nurses' aides entering the computers using the same pathways the nurses were using when inputing their documentation. During an interview, at 4:08 p.m. on 06/14/13, the NCF-1 area staff, Employees #125 (nurse), Employee #95 (aide), and Employee #134 (aide) were asked where the aides document their resident care. They replied they document in the computer. They were asked if they have a separate program or kiosk for the the aides use versus the nurses use and stated they did not. At 9:35 a.m. on 06/20/13, Employee #121 (aide) was observed accessing the dietitian consultation note on Resident #18, when asked to do so by the surveyor. During an interview with Employee #22, (Data Processing Director), at 10:45 a.m. on 06/20/13, she explained and demonstrated the computer's security capabilities. Each staff member was assigned a personal identifying number and the computer program controlled what sections/areas any individual could access or enter data, based on the individual's personal identifier (and, therefore his/her level of professional qualifications). She accessed the medical record on her computer using the identification numbers of two (2) nursing assistants, #106 and #121. In each case, she acknowledged that the aides were allowed to access nurses' notes and flow charts from their entry screen (patient functions). She also acknowledged that changes could potentially be made by them, although she explained that any entry or deletion was locatable to the computer operator via their identification number. She was asked if there was a facility-wide policy/procedure that identified the areas of access allowable for each employee. She stated that she was not sure, although each employee was required to sign a confidentiality statement during their orientation. During an interview with Employee #85 (Medical Records Director), at 10:00 a.m. on 06/24/13, she was asked if there was a facility-wide policy addressing the security of the electronic medical record. She replied that she had not seen one, although she did present a copy of her departmental policy. During an interview with the Administrator, at 10:15 a.m on 06/24/13, he acknowledged that he was aware that the computer system allowed access to parts of the medical record by the aides that they should not have access to. He stated that he would contact the computer company as soon as possible to correct this. He was asked for a copy of a facility-wide policy on security of the electronic medical record and stated he would locate it and present it to the surveyors. At the time of exit there had been no policy presented.",2017-09-01
6964,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,520,F,0,1,WVZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility's quality assessment and assurance (QA&A) committee failed to ensure their facility-wide policy on confidentiality contained verbiage that outlined which employees and contractors were considered authorized users of the medical record and any restrictions or limitations on what could be accessed, prior to implementing the use of an electronic medical record for all resident information. The facility did not identify the authorized user by department and position and the limitations on access to information. After the implementation of the electronic medical record, the facility failed to recognize the electronic medical records charting program in use did not preserve the confidentiality of the resident's medical record by allowing nursing assistants and others to access aspects of the record beyond their scope of need. Additionally, the QA&A committee did not identify and establish effective systems to ensure environmental issues were identified, including a situation that posed an immediate jeopardy to the ambulatory residents on the second floor nursing facility unit not being recognized by the facility. The QA&A committed did not have a system in place to monitor hot water temperatures in residents' rooms, did not have effective systems to ensure residents were free of unnecessary medications and that pharmacist's recommendations were acted upon, did not have an effective maintenance program to ensure kitchen equipment was maintained in a safe operating manner and that the facility was free of pests, did not have a system in place to ensure nurse aides were registered and that nurse aides were provided with twelve (12) hours of in-service education annually as required, did not have a system in place to ensure care plans were established to address the residents needs, and did not have a system in place to ensure the dates weights were taken were identified in the medical record. These issues had the potential to affect all residents, past and present. Facility census: 59. Findings include: a) On the afternoon of the day of entry to the facility (06/17/13), Employee #22 (Data Processing Director) explained to the surveyors how to access the electronic medical record. During the explanation, she stated that both the nurses and aides entered the program via the Patient Functions screen which allowed entry into nurses' notes and flow charts, which should not be accessible to aides, as well as the care plans and aide documentation fields that the aides were responsible for completing. She stated that there was no way to block this access, but she would check further. During an interview with Employee #22, at 10:45 a.m. on 06/20/13, she explained and demonstrated the computer's security capabilities. Each staff member was assigned a personal identifying number and the computer program controlled what sections/areas any individual could access or enter data, based on the individual's personal identifier (and, therefore his/her level of professional qualifications). She accessed the medical record on her computer using the identification numbers of two (2) nursing assistants, #106 and #121. In each case she acknowledged the aides were allowed to access nurses' notes and flow charts from their entry screen (patient functions). She also acknowledged that changes could potentially be made by them, although she explained that any entry or deletion was locatable to the computer operator via their identification number. She was asked if there was a facility-wide policy/procedure that identified the areas of access allowable for each employee and stated that she was not sure, although each employee was required to sign a confidentiality statement during their orientation. During an interview with Employee #85 (Medical Records Director) at 10:00 a.m. on 06/24/13, she was asked if there was a facility-wide policy addressing the security of the electronic medical record and replied that she had not seen one, although she did present a copy of her departmental policy which was based on accepted Health Information Management Guidelines. That policy did address all necessary aspects of access to the medical record for the employees in her department and was based on The American Health Information Management Association guidelines for the use of the electronic medical record. During an interview with the Administrator at 10:15 a.m. on 06/24/13, he acknowledged that he was aware the computer system allowed access to parts of the medical record by the aides that they should not have access to. He stated that he would contact the computer company as soon as possible to correct this. He was asked for a copy of a facility-wide policy on security of the electronic medical record and stated he would locate it and present it to the surveyors. At the time of exit there had been no policy presented. b) Multiple, continuing environmental concerns were identified during the survey, including the existence of a situation that represented immediate jeopardy for [MEDICAL CONDITION] the residents on the second floor nursing unit that was not recognized by the facility until it was pointed out by the survey team. Additional environmental safety issues were also identified. A can of spray disinfectant deodorizer was left in a resident's room where it could be accessed by cognitively impaired residents. Water temperatures in resident rooms were found to be hot enough to [MEDICAL CONDITION] a resident be exposed for three (3) to five (5) minutes. On 06/20/13 at 10:50 a.m. the following temperatures were measured by Employee #77: room [ROOM NUMBER] - 124.0 degrees F room [ROOM NUMBER] - 123.0 degrees F room [ROOM NUMBER] - 123.8 degrees F room [ROOM NUMBER] - 123.9 degrees F room [ROOM NUMBER] - 123.3 degrees F room [ROOM NUMBER] - 122.4 degrees F room [ROOM NUMBER] - 122.6 degrees F room [ROOM NUMBER] - 122.0 degrees F room [ROOM NUMBER] - 121.1 degrees F room [ROOM NUMBER] - 121.1 degrees F room [ROOM NUMBER] - 120.4 degrees F room [ROOM NUMBER] - 120.5 degrees F room [ROOM NUMBER] - 120.3 degrees F On 06/20/13 at 11:25 a.m. the following temperatures were measured by Employee #77: room [ROOM NUMBER] - 111.7 degrees F room [ROOM NUMBER] - 119.0 degrees F room [ROOM NUMBER] - 117.3 degrees F On 06/25/13 at 11:30 a.m., Employee #77 presented records of facility water temperatures. Employee #77 stated the facility did not record water temperatures in resident rooms. c) During the survey, it was discovered that the facility's electronic medical record (EMR) software was not compliant with current accepted standards and practices regarding appropriate restrictions for staff access to protected health information (PHI) depending upon their job classification. The policy and procedure for the design and use of the system did not recognize and address this issue. d) The facility did not have an effective system in place to ensure residents were free from unnecessary medications. Two (2) of eleven (11) residents reviewed for unnecessary medications were found to not have gradual dose reductions, monitoring of targeted behaviors, monitoring of laboratory tests, and/or a nonpharmacologic interventions identified and implemented in an attempt to reduce the use of psychopharmacologic agents. Resident #65 received [MEDICATION NAME] on an as needed (PRN) basis without sufficient identification of the behaviors to be monitored or evidence of behavioral interventions. Resident #18 received [MEDICATION NAME] (an antipsychotic medication and [MEDICATION NAME] (an antidepressant medication), without a gradual dosage reduction. Resident #18 also did not have laboratory testing as recommended by the pharmacist, to monitor the use of [MEDICATION NAME] (an anticonvulsant). The facility also failed to inform the resident/responsible party of the benefits/risks of medications. e) The facility did not have a system in place to ensure recommendations made by the pharmacist were acted upon. On 11/13/12, the pharmacist had made recommendations for a dose reduction of [MEDICATION NAME] as the resident was having increased tremors and had no hallucinations or paranoia. The physician's response for accepting the recommendation was, You know, I didn't start this drug in the first place, I don't think. A pharmacy review, completed on 07/25/12, indicated the resident was receiving [MEDICATION NAME] and [MEDICATION NAME]. It noted the resident had a [DIAGNOSES REDACTED]. It noted [MEDICATION NAME] may antagonize [MEDICATION NAME]'s effects in the treatment of [REDACTED]. If continued a risk versus benefits, indicating it continued to be a valid therapeutic intervention for Resident #18, needed to be completed. The physician declined the recommendation noting the medications were ordered by a neurologist. Employee #98 a licensed practical nurse (LPN), who reviewed pharmacy recommendations and ensured compliance, and Employee # 94, a registered nurse (RN) and nurse manager of the long term care unit, were interviewed on 06/20/13 at 8:50 a.m. They revealed a risk versus benefits had not been completed. They also confirmed the resident had not seen the neurologist for further intervention. Another pharmacy recommendation, dated 06/22/13, revealed a recommendation to decrease [MEDICATION NAME], and noted an annual review was due. Resident #18's most recent minimum data set (MDS) had indicated minimal depression symptoms. The physician declined the recommendation noting a reduction might impair the individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder. The physician's rationale to substantiate his concern was noted as Again. A pharmacy recommendation for serum [MEDICATION NAME] and [MEDICATION NAME] concentrations was initiated on 03/14/13. The rationale was a manufacturer's recommendation because [MEDICATION NAME] is actively metabolized to [MEDICATION NAME]. The physician's declination for obtaining labs was noted as, I didn't start her on this. During an interview with Employee #98 (LPN) and Employee #94 (RN/nurse manager), they confirmed the laboratory tests had not been completed. The physician failed to provide clinical rational, specific to Resident #18, for the continuation of [MEDICATION NAME] or [MEDICATION NAME]. The physician also failed to provide clinical rationale related to the declination of laboratory serum (blood) drug levels related to medications. f) The facility failed to ensure kitchen equipment was maintained in a safe operating condition. During a tour of the kitchen, on 06/18/13, at 1:30 p.m., with Employee #192, (dietary supervisor), observation revealed a knob to the stove was missing, and the stove door had a cloth in the side of the door. A note on the front of the door indicated it was out of order. The dietary supervisor said maintenance had to fix the stove door. She said it needed a spring to stay shut because it flies open. She also said a line inside of the oven needed replaced. The dietary supervisor said she replaced the missing knob for the burner. Further observation revealed the floor of the walk-in freezer was covered with ice. Employee #192 said the door needed to be replaced, because it did not seal properly. She said temperatures were taken twice daily to ensure proper temperatures were maintained. g) Observations and staff interview identified the facility had failed to maintain a pest free environment. The dining room/solarium on nursing Unit 1 was found to have numerous dead gnats trapped in cobwebs behind the blinds and found to have living gnats under a cloth placed on the floor and against the windows which extended to the bottom of the floor. Insects were also found in a resident's room. h) Review of personnel files and staff interview found the facility had failed to obtain registry verification for one (1) of fourteen (14) employees (Employee #116) indicating she was a registered long term care nursing assistant before allowing her to serve as a nurse aide. i) Review of training records and staff interview identified the facility had failed to provide regular in-service education sufficient to ensure the continuing competence of nurse aides (NA), with a minimum of twelve (12) hours per year. This was found for five (5) of five (5) NA files reviewed. Employee identifiers: #103, #104, #107, #109, and #111. j) Based on observation, medical record review, and staff interview, the facility failed to develop an individualized care plan for a resident receiving as needed (PRN) anti-anxiety medication and for a resident who developed a pressure ulcer. Two (2) of twenty-three (23) residents whose care plans were reviewed during Stage 2 were affected. The care plan for Resident #65 did not identify specific behaviors to be monitored and did not identify non-pharmacological interventions to be attempted prior to the administration of PRN [MEDICATION NAME]. The care plan for Resident #38 did not identify measurable goals and objectives when this resident developed a pressure ulcer on the left ankle. k) Based on record review and staff interview, the facility failed to ensure the accuracy of the medical record by recording that weights were measured on a certain date when, in fact, there was no evidence of the exact date the resident was weighed. This was true for all thirty-two (32) residents in the Stage 1 sample. Residents #1, #3, #5, #7, #10, #12, #14, #18, #20, #21, #23, #24, #25, #27, #28, #31, #34, #35, #38, #39, #40, #41, #42, #43, #48, #49, #53, #59, #63, #64, #65, and #66",2017-09-01
8659,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-04-04,225,D,1,0,Q5Z911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of incident reports, policy review, and staff interviews, the facility failed to report and investigate injuries of unknown origin to the appropriate State agencies as required. This was evident for two (2) of four (4) residents' whose incidents were reviewed. Resident identifiers: #63 and #3. Facility census: 58. Findings include: a) Resident #63 Resident #63's medical records were reviewed on 04/02/13 at 10:00 a.m. She was found to be totally immobile and required to be turned and re-positioned by two (2) staff members and moved from bed to chair using a Hoyer lift and two (2) assistants. She was spoon-fed by staff. The resident was only able to move her right fingers. She was unable to move her upper or lower extremities and was non-verbal. The resident was totally incontinent. She was found to have an incident reported on 01/19/13. The report noted an old bruise, greenish in color, the size of a fifty (50) cent piece on the top of her right foot with no known cause. The follow-up documentation on the incident report (typed as written) was, . Remind staff to be careful when repositioning, transferring or placing resident at table. A second incident of unknown cause was documented on 02/09/13. This report noted when bathing the resident, the staff member had found an abrasion on top of the resident ' s left hand. A third incident of unknown cause occurred on 02/13/13, The resident was noted to have a 2 cm bruised area on her left outer eyebrow area. Although all three (3) incidents were injuries of unknown cause, none of the incidents were reported to the State agencies as required by regulation. The annual comprehensive minimum data set assessment, with an assessment reference date (ARD) of 01/24/13, indicated she had not had any falls. She was coded as having no speech, she was rarely/never understood or able to understand others. She was totally dependent for all activities of daily living (ADLs). She did not walk or wheel herself. She was incontinent of bowel and bladder with intermittent catheterizations required. An interview with Employee # 21, a licensed practical nurse (LPN), on 04/03/13 at 10:00 a.m., revealed the resident was totally immobile, except she could move her right fingers and patted herself on her chest. She was unable to turn or reposition herself in bed or chair. The nurse said the resident was a total assist with all aspects of care. Employee #54, a nursing assistant (NA) was interviewed on 04/03/13 at 10:30 a.m. She also said Resident #63 was unable to turn or re-position herself in bed and chair, was total care for all care, and only moved her right fingers to pat herself. An interview, held with Employee #4, the Director of Nursing (DON), on 04/03/13 at 11:30 a.m., confirmed the resident was unable to move independently and all three (3) incidents of unknown cause should have been reported to the appropriate State agencies in accordance with regulations and thoroughly investigated. No documentation could be found to explain the injuries received on all three (3) occasions. An interview with Employee #53, Social Worker (SW), on 04/03/13 at 12:30 p.m. agreed the three (3) incidents should have been reported and investigated. b) Resident #3 Resident #3's medical records were reviewed on 04/02/13 at 2:00 p.m. She had an incident, on 03/18/13 at 8:00 a.m., which was documented as, When getting pt. (patient) OOB (out of bed) this am, pt. stated 'my leg is broke, ' checked rt (right) outer ankle swollen with bruising. Under contributing factors was (typed as written) Was agitated yesterday & was given [MEDICATION NAME] 1 mg IM (intramuscularly). A radiology report, dated 03/18/13 at 6:57 p.m., was attached to the incident report and included, Impression: Acute lateral malleolus fracture with lateral soft tissue swelling. Diffuse osteopenia. No explanation as to cause of the fractured ankle was found in the nursing progress notes. An incident report, completed by Employee #17, a licensed practical nurse (LPN), on 03/21/13 for 03/17/13 at 10:00 p.m., noted, resident moved to the end of her chair and scooted herself onto floor, a CNA (certified nursing assistant) and myself lifted resident from the floor to her chair, no injuries noted, no swelling or bruising noted, no complaints of pain, resident moves extremities without difficulty. Review of the nurses ' notes for 03/17/13, revealed an entry written by Employee #17, LPN at 10:50 p.m., which stated no behaviors noted. Documentation by Employee #22, NA, on 03/17/13 at 11:15 p.m., noted Changed incontinent pad/brief, resident incontinent of urine. This same information was noted on 03/18/13 at 5:47 a.m. No documentation could be found explaining the injury of the resident ' s right ankle. Observations of Resident #3 were made on 04/02/13 from 10:00 a.m. until 11:45 a.m. The resident put her recliner footrest down twice and scooted to edge of the chair for short periods of time and then scooted back into chair. She was observed cursing and verbally talking to residents, staff and visitors during the whole time. The resident was drinking coffee and when a male resident and a female employee became engaged in conversation and would not include her, she threw her coffee cup at the male resident. The resident continued to curse and laugh at others. In an interview with Employee #4, Director of Nursing (DON), on 04/03/13 at 11:30 a.m., confirmed no documentation could be found to explain the injury to the resident ' s right ankle. She said the incident should have reported to the appropriate State agencies and thoroughly investigated. On 04/03/13 at 12:30 p.m., Employee #53, Social Worker (SW), agreed the incident should have been reported and investigated.",2016-04-01
9009,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,157,D,0,1,EZVZ11,"Based on staff interview and medical record review, the facility failed to ensure one (1) of forty-six (46) residents received the services and care necessary to promote their highest level of well-being. The facility failed to notify the resident's physician when the resident experienced hypoglycemic episodes. Facility census: 70. Resident identifier: #27. Findings include: a) Resident #27 Review of the resident's medical record found she had six (6) incidents of a blood sugar level below 60. This occurred on: -- 01/23/12 - blood sugar level 53 - no interventions documented by staff -- 01/07/12 - blood sugar level 43 - no interventions documented by staff -- 12/14/11 - blood sugar level 57 - orange juice was given by staff -- 12/26/11 - blood sugar level 43 - snack was given -- 11/18/11 - blood sugar level 42 - snack was given -- 11/20/11 - blood sugar level 50 - snack was given No evidence could be found the physician had been notified when the resident's blood sugar levels were found to be below 59. Review of the physician's progress note, dated 12/02/11, found he was aware of the glucose level being as low as 59, but no evidence could be found to confirm the physician was notified of blood glucose levels below 59. Employee #17 (director of nursing) was notified of this finding at 10:45 a.m. on 01/30/12.",2016-02-01
9010,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,159,D,0,1,EZVZ11,"Based on review of resident personal funds accounts and staff interview, the facility failed to ensure it had written authorization to handle personal funds for three (3) of eleven (11) residents. The facility handled personal funds for a total of eleven (11) residents. Resident identifiers: #53, #64, and #66. Facility census: 70. Findings include: a) A review of resident accounts with Employee #26 (admissions manager and long term accounts manager), on 01/26/12, at approximately 1:00 p.m., revealed she handled personal funds for eleven (11) residents on the long term care units (Nursing Care Unit I and Nursing Care Unit II). According to Employee #26, the facility handled funds for Resident #53, whose family had recently begun bringing in money for the resident. She said the facility also handled funds for Resident #64, whose son also brought in money for his mother and for Resident #66, who had received an overpayment from an income source. A review of residents' funds account balances revealed Resident #66 had a balance of $33.95 in his account. Resident #53 had a balance of $50.00 in her account and Resident #64 had a balance of $120.00 in her account. Employee #26 verified she did not have signed authorization from the resident or responsible party to handle personal funds for these three (3) residents",2016-02-01
9011,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,164,E,0,1,EZVZ11,"Based on observation and staff interview, the facility failed to provide privacy for residents taking a shower or using the tub in the main shower room on Unit 1. This shower room had no shower curtain in place to provide privacy. The shower curtain rod was on the floor. This had the potential to affect all residents on Unit 1. Facility census: 70. Findings include: On 01/23/12 at 12:30 p.m., observation of the main shower room on Unit 1, found the shower curtain rod on the floor of the shower room and no shower curtain in place. On a tour with the administrator (Employee #150), on 01/25/12 at 12:30 p.m., the administrator observed the shower curtain rod on the floor and no hanging shower curtain. This employee agreed if a resident was receiving a shower or tub bath, no privacy would be provided. Observation of the shower room, on 01/26/12 at 2:00 p.m., found the shower curtain and rod were in place in the Unit 1 main shower room.",2016-02-01
9012,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,225,E,0,1,EZVZ11,"Based on review of personell files and staff interview, the facility failed to ensure they had conducted thorough investigations into the backgrounds of four (4) of ten (10) employees. These four (4) employees had listed employment outside the State of West Virginia within the past seven (7) years. The facility did not make reasonable efforts to uncover information about past criminal prosecutions in states other than West Virginia. This practice had the potential to affect more than an isolated number of residents. Employee identifiers: #189, #193, #183, #203, and #195. Facility census: 70. Findings include: a) On 01/26/12, at approximately 10:00 a.m., an interview with Employee #46 (human resources) revealed four (4) of ten (10) employee files did not have evidence of thorough background screenings. These individuals had been employed in other states, but the facility had not conducted an investigation of their past histories in those states when considering them for employment. - Employee #203, a nursing assistant, was hired on 10/18/11. This individual listed employment in another state within the past five (5) years. - Employee #203, a nurse aide, listed employment in three (3) different locations within another state. Her most recent employment in that state was in 2008. - Employee #189, the social worker, had worked in another state in 2007. - Employee #193, a licensed practical nurse (LPN), was hired on 05/31/11. Information in her file indicated she had been employed in another state in 2007. On 01/26/12, at approximately 11:00 a.m., Employee #46 presented copies of the criminal background checks that had been completed by the West Virginia State Police. She indicated the hospital had not screened these four (4) employees in other states where these individuals had previously been employed.",2016-02-01
9013,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,241,E,0,1,EZVZ11,"Based on observation and staff interview, the facility failed to provide care in an environment that provided and maintained each resident's dignity. Eight (8) of nine (9) residents were not treated in a dignified manner at meal time. One (1) resident, seated at a table with eight (8) other residents, received his meal while the other eight (8) residents had to sit and observe him eating. Facility census: 70. Resident identifiers: #86, #48, #29, #61, #10, #24, #19, #70, and #9. Findings include. a) Residents #86, #48, #29, #61, #10, #24, #19, #70, and #9 Observation of the dining experience on 01/23/12, found nine (9) residents seated at one (1) table. The speech therapist retrieved the tray for Resident #70, then sat with him and assisted him with his meal. The other eight (8) residents, seated at the same table, did not receive their lunch trays for fifteen (15) minutes after Resident #70 had begun eating. This finding was reported to Employee #150 (administrator) and Employee #17 (director of nursing) at 11:00 a.m. on 01/30/12.",2016-02-01
9014,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,242,D,0,1,EZVZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident observation, treatment record review, and staff interview, the facility failed to ensure one (1) of forty-six (46) residents received a sufficient amount of fluids based on the resident's individual needs. Resident #83 received hospice services and had a [DIAGNOSES REDACTED]. The facility had an order for [REDACTED].#83. Facility census: 70. Findings include: a) Resident #83 On 01/25/12, at approximately 2:00 p.m., the medical record review for Resident #83 revealed he came to the facility on [DATE] from the hospital. His record showed he had capacity to make his own medical decisions. He had a [DIAGNOSES REDACTED]. Further review of the record revealed a treatment record dated 01/16/12. The treatment record indicated the facility had placed the resident on a 2,000 cc fluid restriction on 01/16/12. The physician's orders [REDACTED]. (Pitting [MEDICAL CONDITION] may be classified as 1+ to 4+. With 3+ or 4+, the leg will look swollen) On 01/23/12, at approximately 4:00 p.m., the resident was observed using his water pitcher and getting ice chips out to moisten his mouth / throat. On 01/25/12, at approximately 1:30 p.m., Employee #133 (licensed practical nurse) indicated she did not know the resident required a fluid restriction. She reviewed the treatment record and said she would have to consult with dietary as well as the nursing staff if they were to initiate this fluid restriction. She said he often asked for ice and she was not sure if he would comply with a fluid restriction. On 01/25/12, at approximately 2:00 p.m., Employee #133 indicated she had spoken with the director of nursing (Employee #17) about the fluid restriction and planned to discuss the issue with the resident. She later stated she had spoken with Resident #83 and he told her he did not want any type of fluid restrictions. On 01/30/12, at approximately 11:00 a.m., the director of nursing verified again that the staff had spoken with the resident and he declined the fluid restriction.",2016-02-01
9015,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,244,E,0,1,EZVZ11,"Based on a review of the resident council minutes and staff interview, the facility failed to act upon resident complaints The minutes reflected repeated concerns regarding missing clothing, laundry detergent, and food / meal issues over a six (6) month period. This had the potential to affect more than an isolated number of residents. Facility census: 70. Findings include: a) Review of the resident council meeting minutes, for 07/28/11 through 12/29/11, revealed the residents attending the meetings had expressed concerns regarding the laundry detergent, orders to the kitchen not being filled, the menu not being posted where residents could see it, and missing clothing. The minutes for 07/28/11, noted Still an issue with missing clothing. The minutes of 08/25/11 noted Other topics talked about were: ordering food from cafeteria menu, the menu not being out where they can see it, and ordering seconds on the meals if they want. The meeting minutes for 11/17/11 included dietary questions. Again on 12/29/11, there was a complaint about missing clothing. There was also a complaint about the laundry detergent. The minutes noted A lot of residents had the same concern. These minutes also included Substitution list is not substantial. Would like another meat alternative . It's always the same thing. The minutes for all of these meeting reflected no follow up response to these voiced concerns. In an interview, on 01/26/12 at 12:00 p.m., the administrator (Employee #150) agreed there was no evidence the facility had acted upon the concerns expressed by the residents, nor was there evidence the resident had been informed of the status of their complaints / concerns. The administrator could provide no evidence the concerns had been addressed and / or resolved.",2016-02-01
9016,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,252,E,0,1,EZVZ11,"Based on observation, staff interview, and medical record review, the facility failed to provide a comfortable, safe, and homelike atmosphere as evidenced by meals being left on trays, and domed lids and paper debris scattered on the tables while residents ate. This had the potential to affect all residents eating their meals in Unit 1 and Unit 2 dining rooms. The room of one (1) of forty-six (46) Stage II sample residents appeared unkempt and had avoidable trip hazards, despite the resident having a history of falls. Resident identifiers: #27 and all residents eating meals in the dining areas on Units 1 and 2. Facility census: 70. Findings include: a) On 01/23/12 at 12:00 p.m., observation of the Unit 2 dining area revealed residents were served on trays. The meals were not removed from the trays. The domed lids were left sitting on the tables, in resident view while eating, after they were removed for the meal service. The domed lids contained paper debris from the butter, plastic bags, empty sugar packets, and wrappers that had contained salt and pepper. On this same day, at approximately 12:30 p.m., observation of the Unit 1 dining area revealed these residents were served their meal in the same manner. Random observations, made from 01/24/12 through 01/26/12, found the same conditions during the lunch meal. b) Resident #27 During a tour of the facility, on 01/23/12, Resident #27's room was observed by two (2) surveyors to be cluttered and in a disorganized fashion. The bed was covered with briefs, stuffed animals, shoes were on the floor, a glider rocker was in the middle of the floor, and items were stacked on the dresser. Review of the medical record for Resident #27 found she had fallen in her room on 12/29/11. Her care plan verified she was at high risk for falls. The unkempt appearance of the room and the potential trip hazards were discussed with Employee #150 (administrator), at approximately 10:45 a.m. 01/31/12.",2016-02-01
9017,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,253,E,0,1,EZVZ11,"Based on observation and staff interview, the facility failed to provide housekeeping and maintenance serviced necessary to maintain a clean, sanitary, and orderly environment. Observations found numerous unclean areas on Unit 2. These areas included the resident kitchen, shower room, soiled utility room, clean utility room, and storage room. Furthermore, on Unit 1, it was noted the main shower room had a shower curtain rod on the floor, and ceiling tiles were missing, exposing pipes and wiring. In other areas there were items stored on the floor, boxes stored in front of a breaker box, and multiple boxes of adult briefs stored in the hallway. This had the potential to affect more than an isolated number of residents. Facility census: 70. Findings include: a) Unit 2 1) On 01/23/12 at 12:40 p.m., observation revealed the Unit 2 shower room had missing ceiling tiles resulting in pipes and wiring being exposed. The storage room had multiple bags of clothing and bolsters stored on the floor. An intravenous (IV) pump was lying on the floor. At 12:45 p.m., on this same day, observation revealed the biohazard room had boxes of yellow bags stored directly on the floor. The hopper had brown debris around the rim and multiple yellow colored splash marks. An uncovered cart containing pillows and cushions were stored next to the hopper where the items were subject to being splashed. A picture and bulletin board were on the floor. 2) On 01/25/12 at 11:10 a.m., observation of the resident kitchen, on Unit 2, revealed the coffee pot and coffee dispenser were on a cabinet with a pressed wood top. The top contained multiple spill marks and was warped. The microwave had multiple splatters on the inside. The refrigerator had spills and debris on the shelves and the door. A two (2) burner hot plate had brown debris around the burners. On 01/25/12 at 11:20 a.m., the director of nursing (DON - Employee #17), was shown the areas on Unit 2. She agreed with all of the findings on this unit. b) Unit 1 At 1:15 p.m., on 01/23/12, observation on Unit 1 revealed a shower curtain rod and towel bar lying on the floor of the main shower room. The storage room contained boxes of adult briefs stored in front of a breaker box. (The National Electric Code (NEC) prohibits storage of items within three (3) feet of a breaker box.) On 01/25/12, at approximately 12:00 p.m., the administrator (Employee #150) was informed of the above findings. On 01/26/12, at approximately 11:30 a.m., observation revealed all of the above issues had been corrected.",2016-02-01
9018,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,279,D,0,1,EZVZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interview, the facility failed to develop a comprehensive care plan for each resident that described the services to be provided to assist the resident in attaining or maintaining his or her highest practicable levels of well-being. One (1) resident did not have an individualized care plan, based on his comprehensive assessment, for urinary incontinence. Another resident had an infection for which additional precautions were indicated, but no care plan had been established to address those needs. Two (2) of forty-six (46) residents on the Stage II sample were affected. Resident identifiers: #78 and #70. Facility census: 70. Findings include: a) Resident #78 The medical record for of Resident #78 was reviewed at 11:21 a.m. on 01/25/12. 1) Upon admission, a bladder assessment had been conducted from 11/10/11 through 11/17/11. It indicated the resident was incontinent all the time. According to the assessment, the resident had not utilized the call bell. He was noted to take fluids independently and was able to ask for them. He did not refuse fluids when offered, and averaged 2000 ml intake on day shift, 1200 ml intake on afternoon / evening shift, and 240 ml on night shift. He was noted to have been incontinent 3 times on each shift during the 7 day review period. He was assessed as being unable to tell when his bladder was full or when he was wet. According to the assessment, he dribbled urine with movement. The resident was determined to have functional incontinence. The section of the bladder assessment that stated use the following guidelines to determine appropriate program for resident had sections for containment program, management program, and bladder retraining program. None of these programs had been marked to indicate the appropriate program to be implemented for Resident #78. 2) His Minimum Data Set (MDS 3.0) assessment of 11/20/11 assessed him as requiring extensive assist of one (1) staff for toilet use. He was coded as having been frequently incontinent in the seven day look-back period. The assessment was coded that a trial toileting program had not been attempted. 3) The care plan for Resident #78 included a problem identified as alteration in patterns of urinary elimination related to decreased physical ability as evidenced by functional urinary incontinence, dated 11/20/11. The stated goal was: resident will not experience any complications related to urinary incontinence through review date (02/16/12). Interventions for this goal included (typed as written): 1. Implement bladder re-training program with all personnel and resident if appropriate. 2. Observe voiding pattern determine what, if any stimuli precipitate voiding. 3. Encourage adequate fluid intake with meals, with medications, on room visits, and with hydration pass at 6a, 2p, and 8p. 4. Comprehensive evaluation of incontinence pattern to determine potential for management program. 5. Encourage to empty bladder first thing in the morning, before meals, at bedtime, before activities. 6. Keep skin clean, dry, and free of odor at all times. 7. Labs as ordered , monitor results. 8. clear pathway in resident's normal route to/from bathroom and to sink. 9. Assist to toilet as needed. 10. Promptly clean and dry skin after each incontinent episode. 11. Toilet per individual toileting plan. 12. Monitor for non-verbal indicators of the need to toilet. 13. Maintain resident's dignity during incontinency care. 14. Provide clothes that are easy for the resident and staff to manage when he needs to toilet. 15. Encourage resident to avoid beverages that stimulate urination such as cola, coffee, tea, and grapefruit juice. 16. Avoid excessive fluid intake after 5 pm to decrease nocturia. 17. Consider possible contributing factors to incontinence such as medications, infection, or depression. 18. Monitor for indication of symptomatic UTI and report to MD promptly. Administer [MEDICATION NAME] as prescribed. Monitor for urine retention. An interview was conducted with the registered nurse responsible for the bladder management program, Employee #101 at 10:40 a.m. on 01/26/12. When asked about the admission assessment and initial care plan for this resident, she stated Resident #78 was not appropriate for a bladder retraining program, that he should have been placed on a management program upon admission. She acknowledged there was still no toileting plan completed, nor any bladder management program specified, as yet for Resident #78. The nurse agreed the care plan was a generic listing of interventions that had not been individualized to meet the needs of Resident #78. b) Resident #70 The resident's most recent care plan, revised on 01/23/12, failed to address the resident's [DIAGNOSES REDACTED]. (VRE is an epidemiologically important infectious microorganism that is resistant to many antibiotics. It can be spread by direct or indirect contact with the resident or the resident's environment. The Centers for Disease Control (CDC)recommends contact isolation in addition to standard precautions for multiple-drug resistant organisms such as VRE. Special cleaning procedures may be indicated for the environment.) Interview of direct care staff, on 01/25/12 at 3:35 p.m., found they did not know the resident was to be on any type of isolation. During observation of this resident, on 01/25/12 at 3:35 p.m., it was discovered the nursing assistant had changed the resident's brief and disposed of it in the geri chair next to the resident's bed. Resident #70 was found to be in bed with no brief on to assist in containing the urine. The care plan did not reflect any specific interventions or precautions, in addition to standard precautions, for staff to follow to prevent the spread of this infection. During an interview with Employee #17 (director of nursing) on 01/25/12 at 3:35 p.m., she was unaware of the resident's [DIAGNOSES REDACTED]. Employee #17 contacted Employee #47 (infection control nurse), who was aware of the findings. It was discovered the infection control nurse had received and signed the final results from the laboratory services, but failed to communicate with other members of staff. It was verified, on 01/30/12 at 10:42 a.m., the laboratory results had been signed by Employee #47 on 01/22/12, but were not communicated to anyone else in the facility.",2016-02-01
9019,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,280,D,0,1,EZVZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure care plans were evaluated and revised as the residents' status changed for two (2) of forty-six (46) residents on the sample. Care plans were not revised to reflect a change in diet or weight loss. The care plan was not revised when the resident did not utilize a wheelchair in accordance with her established care plan. Another Resident identifiers: #18 and #49. Facility census: 70. Findings include: a) Resident #18 This [AGE] year-old woman was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident's medical record was reviewed on 01/16/12 at 8:00 a.m., and again at 9:30 a.m. on 01/30/12. 1) She was ordered a pureed diet. It was also noted she could have soft foods. Supplements ordered included Prosource, one (1) ounce each morning, Magic Cup with supper, Ensure pudding each morning, and may add soup to lunch and dinner. Her admission weight was 107 pounds. She was 4'10 tall. Her minimum data set (MDS) of 12/22/11 documented she required extensive assistance of one (1) staff member for eating. Dietary had assessed the resident upon admission. The assessment included her current nutritional needs were not being met through oral intake. She was placed on supplements, and a referral was made for speech therapy to evaluate. The dietitian's note, on 01/20/12, included, Nutrition update: Wt. 1/10/12 95.5, 1/15/12 97. Wt decrease 12% last 30 days, significant weight change. BMI=21. Diet: puree, may have soft foods with prosource 1 oz 1 time a day, magic cup at dinner, and Ensure pudding 1 time each day. Meal intake 25 - 50% Feeds self with assistance. No chewing or swallowing difficulty noted. Medications reviewed. Skin intact. Good acceptance of supplements per nursing. Will recommend to add two cal HN 60ml 3x/d with med pass to provide 354 cal and 12 g protein of 1/20/12, following significant weight loss; resident still within IBW. This recommendation was implemented by physician's orders [REDACTED]. A speech therapy consult was ordered for the resident on 11/16/11. The physician requested a swallowing evaluation be done due to the resident not tolerating a mechanical soft diet, being unable to chew, and spitting out food. A review of the speech therapist's documentation was conducted at 9:00 a.m. on 01/26/12. The speech therapist performed a swallowing evaluation on 11/16/11. Her diet was changed to pureed and she could have very soft chewables, such as chicken noodle soup, cottage cheese, etc. The [DIAGNOSES REDACTED]. Her meal intake increased from 32% to 47.7% following the diet change. Her intake was assessed as stable and speech therapy services were discontinued on 12/09/11. Review of the care plan found it had not been updated to reflect the change in diet from mechanical soft to pureed. 2) A care plan goal for the resident to maintain her present weight until thenext review had been established. The weight listed on the care plan remained at 107 pounds, which was her admission weight. Her weights since admission were: 09/13/11 107 09/27/11 104 10/11/11 103 11/05/11 106 12/07/11 109 01/10/12 96 01/15/12 97 There was one revision to the care plan noted on 01/26/12. This was to add Two Cal HN 60ml 3x day with med pass. The date of the weight maintenance needed problem was 12/22/11. The diet was changed from mechanical soft to pureed on 11/16/11. Neither the diet change, nor the significant weight change had been reflected on the care plan. An interview was conducted with director of nursing (DON), Employee #17 at 11:00 a.m. on 01/30/12. She concurred the care plan had not been updated, when review on 12/22/11, to reflect the change from a mechanical soft diet to a pureed diet which had taken place on 11/16/11. The care plan had not been revised to reflect the resident's ten (10) pound weight loss. b) Resident #49 The care plan review for Resident #49, conducted on 01/25/12, at approximately 10:00 a.m., revealed Resident #49 had a risk for injury related to short term memory issues, a past fall and a recent fall that had resulted in a fracture, as well as medications that increased the risk of falls, and an environment that created an increased risk for falls. The medical record, revealed she had sustained a fracture to her left hip and required a partial hip replacement in August 2011. This was verified through a family interview. The care plan created for this problem, dated 10/25/12, stated Up to wheelchair for mobility. Monitor for attempts to get up unassisted. On 01/25/12, at approximately12:00 p.m., Employee #7 (licensed practical nurse) stated Resident #49 had not used her wheelchair in a long time. She said the physical therapy department had tried the wheelchair with the resident, but she was not receptive to its use. She would often forget to use the wheelchair and when she did use it, she would not keep the wheels locked. Employee #7 said the resident did use a walker and they encouraged her to use it, but due to her [DIAGNOSES REDACTED]. Resident #49 was not observed using the wheelchair during observations made from the time period of 01/23/12 through 01/26/12. The resident's care plan was not revised to address the issues regarding the resident's use, or lack of use, of the wheelchair and / or walker.",2016-02-01
9020,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,282,D,0,1,EZVZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to implement interventions determined necessary in the care plan of one (1) of forty-six (46) stage 2 sampled residents. The resident's care plan included monitoring for orthostatic [MEDICAL CONDITION]. However, there was no evidence found this was being monitored. Resident identifier: Resident #55. Facility census was 70. Findings include: a) Resident #55 This was a [AGE] year old female with medical [DIAGNOSES REDACTED]. On 01/30/12 at 2:00 p.m., a review of Resident #55's care plan, dated 01/05/12, revealed interventions of Monitor for orthostatic [MEDICAL CONDITION]. No evidenced was found in the medical record this resident had been assessed for orthostatic [MEDICAL CONDITION]. On 01/30/12 at 3:30 p.m., in an interview with the director of nursing (DON - Employee#150), she agreed there was no monitoring for orthostatic [MEDICAL CONDITION]. The DON provided a copy of a nurse's note which reflected Resident #55 had been evaluated for orthostatic [MEDICAL CONDITION] on 01/30/12 at 1500 (3:00 p.m.). However, no evidence of monitoring was provided.",2016-02-01
9021,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,309,D,0,1,EZVZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to ensure one (1) of forty-six (46) residents received the services and care necessary to promote his / her highest level of well-being. The facility failed to provide blood sugar monitoring as ordered by the physician. Facility census: 70. Resident identifier: #27. Findings include: a) Resident #27 This resident had a [DIAGNOSES REDACTED]. 1) Review of the resident's diabetic management sheet found on numerous occasions, the facility had failed to obtain a level and record it on the monitoring flow sheet. Missing information was as follows: -- Only one (1) blood sugar level was recorded, unless otherwise noted, on the following dates: -- 10/02/11 -- 10/13/11 -- 10/21/11 -- 10/22/11 -- 10/27/11 -- 11/21/11 -- 11/23/11 -- 11/27/11 *no recordings -- 12/01/11 *no recordings -- 12/02/11 *no recordings -- 12/03/11 -- 12/05/11 -- 12/16/11 -- 12/19/11 -- 12/20/11 -- 12/25/11 -- 12/26/11 -- 12/27/11 -- 01/21/12 Employee #17 (director of nursing) was notified of this finding at 10:45 a.m. on 01/30/12.",2016-02-01
9022,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,323,E,0,1,EZVZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure the resident environment was as free of accident hazards as possible; and that each resident received adequate supervision to prevent accidents. A resident's personal alarm sounded for twelve (12) minutes without staff intervention, even though two (2) staff members passed the room. The room of another resident, who had a history of [REDACTED]. A shower curtain rod and towel bar were observed lying on the floor in the main shower room on Unit 1. This too created trip hazards for any resident entering the shower area. This was found for two (2) of forty-six (46) residents on the Stage II sample and had the potential to affect any resident entering the shower area on Unit 1. Resident identifiers: #78 and #27. Facility census: 70. Findings include: a) Resident #78 Resident #78 was assessed as being at high risk for falls upon his admission on 01/08/11, and again on subsequent assessments on 01/08/12 and 01/20/12. He was determined to be at risk for falls due to a lack of balance, use of medications, and dementia. His MDS 3.0 of 11/20/11 indicated he required the extensive assistance of one (1) person for bed mobility, transfers, and walking. His balance was assessed as not steady and he was only able to stabilize with human assistance. He was coded as having a fall in the last 2-6 months prior to admission. The resident's care plan was reviewed at 9:00 a.m. on 01/25/12. There was a care plan for risk for injury related to medications, Parkinson's disease, and schizophrenia, dated 11/20/11. The stated goal was the resident would not experience a fall or other injury for the next 90 days. Among the approaches listed (typed as written) were: 1. Therapy services evaluation of needs every three (3) months and with any significant change in status. 2. Keep resident close to area that is supervised. 3. Monitor resident for proper use of assistive devices. 4. Encourage to request assist in ambulating. 5. Assess cause, pattern of previous falls & act upon resolvable factors. 6. Quarterly fall risk assessment. 7. Ensure that alarmed exits are functional at all times. 8. Discuss reasons for safety/protective measures with resident and family. 9. Call bell within reach at all times. 10. Answer call bell promptly. 11. Identify resident as a high fall risk through the hospital's falling star program. 12. Maintain bed in lowest position. 13. Ensure that brakes are engaged prior to transfers. 14. Ensure that all equipment is in proper working order. 15. Side rails up by 50% for mobility. 16. Monitor for complications related to side rails, such as entrapment risks. 17. Osteoporosis! 18. Frequent monitoring by staff. 19. Maintain bed in lowest position. 20. Monitor for allergies [REDACTED]. 21. Resident is allergic to tine test PPD. 22. For safe transfer/ambulation, resident requires 1 person assist and walker for mobility. An additional approach, added on 01/17/12 stated pressure alarm for bed/chair for safety. Nurses had documented falls for this resident on 01/08/12, 01/12/12, and 01/20/12. Reports and notes for the falls were reviewed at 4:00 p.m. on 01/25/12. The report for the fall of 01/08/12 noted the resident had been found kneeling on the floor in his room beside his bed by a nursing assistant. Contributing factors were noted as Resident has a history of taking self to bathroom. Under the section Ideas of how this could have been prevented was written: Personal alarm - Bed alarm? The report for the fall of 01/12/12, noted the resident had been found on the floor in the solarium with a slight scrape on his back. Under the section Ideas of how this could have been prevented was written: Encourage res (resident) to leave pull alarm on & to use w/c (wheelchair). Staff to be aware of res & check alarm often. Under the section Additional comments or follow-up was written 1-17-12 Resident continues to unhook his pull alarm - will add pressure release alarm while he is in the wheelchair. This intervention was ordered by the physician in a telephone order on 01/17/12. A note was provided by staff that indicated the resident had been found sitting on his knees in front of his bed, with no injuries noted. A form entitled Physical Restraint Management to Promote Functional Independence was completed by Physical Therapy on 01/24/12. Under the section Recommendations was written monitor closely. The type of restraint noted was pressure release alarm - bed & chair. Resident #78 was observed in his wheelchair just outside his room at 9:48 a.m. on 01/25/12. Staff were discussing that he was going to get his hair cut. Then, it was found out he was not scheduled to get his hair cut until the next day. He was left in his wheelchair and placed in his room. At 9:55 a.m., an alarm was heard sounding that appeared to be coming from somewhere around Resident #78's room. Observation from an area adjacent to the resident's room found he had gotten out of his wheelchair, and ambulated into his bathroom. He closed the door loudly. No staff had responded to the audible alarm, which was still sounding. At 10:04 a.m., a nursing assistant, Employee #71, was observed walking down the hall, passing Resident #78's room. The alarm was still sounding in the empty wheelchair, which was located facing the door to the room, approximately five (5) feet from the entrance. She continued down the hall, going into another resident's room. At 10:07 a.m., another nursing assistant, Employee #184, was observed walking down the hall passing Resident #78's room. The alarm continued to sound. She too continued down the hall without checking the alarm. At 10:12 a.m., Resident #78 was observed to leave the bathroom. He sat down in his wheelchair, which silenced the pressure sensitive alarm. The alarm had sounded for twelve (12) minutes without any staff response, including two (2) nursing assistants who walked directly in front of the doorway as the alarm sounded. An interview was conducted with director of nursing (DON), Employee #17, at 10:30 a.m. on 01/25/. The earlier observations regarding Resident #78 were discussed. Following the discussion, she voiced understanding. b) Resident #27 During a tour of the facility on 01/23/12, Resident #27's room was observed by two (2) surveyors to be in a disorganized fashion. The bed was covered with briefs and stuffed animals, there were shoes on the floor, a glider rocker in the middle of the floor, and items were stacked on the dresser. Employee #150 (administrator) was informed of the findings on 01/31/12 at 10:45 a.m. Review of the medical record for Resident #27 found she had fallen in her room on 12/29/11. The disarray found in the resident's room was not conducive to a safe environment as there were trip hazards. Employee #17 (director of nursing), when interviewed at 1:05 p.m. on 1/25/12, was unaware of the resident's fall. She stated, This is the first I have heard of it. c) Unit 1 shower room On 01/23/12 at 1:15 p.m., observation on Unit 1 revealed a shower curtain rod and towel bar on the floor of the main shower room. This was a potential trip hazard for residents using this shower room.",2016-02-01
9023,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,354,F,0,1,EZVZ11,"Based on staff interview and review of the facility's scheduling calendar, the facility failed to have a registered nurse for at least eight (8) consecutive hours a day, seven (7) days a week. Facility census: 70. Findings include: Review of the facility's scheduling calendar for December 2011 and January 2011 found the facility failed to schedule a registered nurse on four (4) separate days. On December 14, 2011, December 15, 2011, January 28, 2012, and January 29, 2012, the facility had no registered nurse scheduled to work. At 11:00 a.m. on 01/30/12, the director of nursing (Employee #17) verified the facility did not have registered nurse coverage on those dates.",2016-02-01
9024,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,356,B,0,1,EZVZ11,"Based on observation and staff interview, the facility failed to post staffing data as required by the regulations. During the initial tour of the facility, the information was not posted for public view. Facility census: 70. Findings include: a) During the initial tour of the facility, on 01/23/12, it was discovered the facility had not posted the required staffing information. Further review of the past staff postings found incomplete staffing information. The staff posting failed to identify the total number of hours worked, the category numbers of staff working, and some shifts were missing all of the required information. This finding was presented and verified by the director of nursing (Employee #17) at 11:00 a.m. on 01/30/12.",2016-02-01
9025,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,360,B,0,1,EZVZ11,"Based on a review of the facility's disaster menu and staff interview, the facility failed to ensure they had prepared a menu that provided each resident with a nourishing, palatable, well-balanced diet that met the daily nutritional and special dietary needs of each resident. Twelve (12) of seventy (70) residents received a pureed diet. The facility's emergency menu had food items that did not meet the needs of resident's who received a pureed diet. Resident identifiers: #80, #70, #48, #18, #10, #24, #30, #32, #22, #26, #49, and #26. Facility census: 70. Findings include: a) On 01/26/12, at approximately 10:00 a.m., the dietary manager (Employee #92) assisted in the review of the facility's emergency menu. The menu called for the following items at dinner: - Day one: Vegetable juice, peanut butter, jelly, corn, tortilla chips, cookies, milk, salt, pepper, and sugar -Day two: Tomato juice, canned pork/ham, baked beans, potato chips, vanilla wafers, hard candy, milk, salt, pepper, and sugar -Day three: Vegetable juice, tuna, mayonnaise, carrots, tortilla chips, graham crackers, jelly beans, milk, salt, pepper, and sugar The menu indicated the facility had the following pureed items: Chicken, pork or ham, fish, jar baby cereal, carrots, green beans, peas, peaches, pears, and apricots. The dietary manger indicated her consultant dietitian had reviewed the menu and approved of the selections. The menu indicated hard candy and jelly beans would be omitted based on individual tolerance for those on ground and pureed diets. On 01/26/12, at approximately 12:00 p.m., the dietary manager said the staff would provide mashed potatoes in place of potato chips or tortilla chips for those on pureed diets. She said the facility could offer Jell-O in place of the hard candy / jelly beans. On 01/30/12, at approximately 10:00 a.m., the dietary manager indicated she had spoken with the registered dietitian and had come up with some adjustments to the emergency menu. She provided a copy of the new menu. The bottom of the menu stated substitute pureed foods or nutritional supplement. Omit jelly beans on individual tolerance. Substitute instant mashed potatoes for tortilla chips and potato chips. On 01/30/12, at approximately 1:00 p.m., the facility's diet orders were reviewed. The following residents received pureed diets: Resident #80, #70, #48, #18, #10, #24, #30, #32, #22, #26, and #49. The dietary manager agreed the previous menu did not give the staff a food item of equal nutritive value with which they could replace the tortilla and potato chips should they need to utilize the emergency menu.",2016-02-01
9026,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,371,F,0,1,EZVZ11,"Based on observation and staff interview, the facility failed to ensure foods were prepared and served under sanitary conditions, and failed to reduce practices which had the potential to result in food contamination and compromised food safety. These practices had the potential to affect all residents who received nourishment from the dietary department and resident pantry areas. Facility census: 70. Findings include: a) Kitchen The kitchen was toured, on 01/23/12 at 12:45 p.m., with Employee #34 (special function coordinator). 1) The following problems were noted for foods stored in the walk-in refrigerator: - a boiled egg in a plastic bag was found with no date - pepperoni in a plastic bag with no date - one piece of corn bread in a plastic bag with no date - a Styrofoam container with an onion slice, lettuce, and pickles not dated - a salad covered with plastic wrap with no date - a plastic bag containing cheese with no date The above items were not dated so dietary staff could determine how long each product had been opened and whether it was still safe for consumption. 2) The ice cream freezer contained no thermometer. The above findings were reported to Employee #150 (administrator) on 01/30/12 at 11:00 a.m. b) Resident kitchen, Unit 2 On 01/25/12 at 11:10 a.m., observation of the resident kitchen, on Unit 2, revealed the coffee pot and coffee dispenser were on a cabinet with a pressed wood top. The top contained multiple spill marks and was warped. The microwave had multiple splatters on the inside. The refrigerator had spills and debris on the shelves and the door. A two (2) burner hot plate had brown debris around the burners. On 01/25/12 at 11:20 a.m., the director of nursing (DON - Employee #17), was shown the condition of the resident kitchen. On 01/25/12 at approximately 12:00 p.m., the administrator (Employee #150) was informed of the above findings. b) Resident kitchen on Unit 1 On 01/23/12 at 12:55 p.m., observation of the resident kitchen on Unit 1 revealed temperatures of the beverage refrigerator had not been monitored. This refrigerator contained milk products, juices and various types of soda. In an interview with the charge nurse (RN - Employee #7), on 01/23/12 at 1:10 p.m., she agreed the temperatures of the beverage refrigerator had not been monitored.",2016-02-01
9027,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,386,D,0,1,EZVZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a physician reviewed the residents' total program of care at the time of each visit by signing and dating all orders in a timely manner as required. This was found for three (3) of forty-six (46) residents reviewed. This practice had the potential to affect all residents. Resident identifiers: Residents #78, #29, and #13. Facility census: 70 Findings include: a) Resident #78 The resident's medical record was reviewed at 11:21 a.m. on 01/25/12. During the review, it was discovered there were no physician's signatures on any orders since the resident's admission on 11/08/11. The attending physician for Resident #78 was Employee #5. On 01/25/12 at 10:00 a.m., the director of nursing, (DON), Employee #17, was asked to locate any physician's signatures on any orders in the record of Resident #78. During an interview on 01/25/12 at 11:25 a.m., the DON confirmed there were no orders signed by the physician in the medical record of Resident #78. b) Resident #29 The medical record for Resident #29 when reviewed on 01/25/12. It was found the resident's attending physician had visited on 08/31/11. At that time, the physician wrote a progress note, but failed to acknowledge by signing and dating the progress note. Further review found the physician's monthly orders had not been signed for July 2011, August 2011, September 2011, October 2011, and November 2011. According to the medical record, the physician's assistant had seen the resident on 10/19/11 and 03/31/11. The physician failed to acknowledge by co-signing the two (2) visits made by the physician's assistant. Further review of the medical record found numerous unsigned telephone orders made by the physician on 06/15/11, 06/25/11, 08/25/11, 09/16/11, 09/28/11, 10/3/11, 10/17/11, 11/4/11, 12/15/11, and 12/16/11. This finding was discussed with Employee #17 (director of nursing) at 11:00 a.m. on 01/30/12. c) Resident #13 A review of the medical record of Resident #13 revealed he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's progress notes documented a visit by the physician on 08/31/11. There was a partial note that was unsigned on 10/19/11, but appeared to be by the physician. The following are only a few of the verbal orders that were taken and documented by nursing: 11/03/11: Changes in insulin coverage, 11/04/11: Wound care instructions, and 11/06/11: Medication orders. None of these orders showed evidence they have been reviewed and signed by the physician. There was no evidence in the record the physician had visited the resident except on 08/31/11, and possibly on 10/19/11 (when the unfinished note was written). This was verified by Nurse #151 who reviewed the record, including the nurses' notes, at 12:30 p.m. on 01/30/12. She confirmed the verbal orders had not been signed by the physician, although there were many red flags on many pages of the physician's orders. During an interview with the director of nurses, at 2:00 p.m. on 01/30/12, she acknowledged the orders should have been signed prior to this date.",2016-02-01
9028,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,387,E,0,1,EZVZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. This was found for five (5) of forty-six (46) residents on the Stage II sample. Resident identifiers: Residents #78, 29, #55, #13, and #49. Facility census: 70. Findings include: a) Resident #78 Medical record review, on 01/25/12 at 11:21 a.m., found there were no physician's progress notes documenting visits to review the resident's total program of care, including medications and treatments, since the resident's admission on 11/08/11. The attending physician for Resident #78 was Employee #5. On 01/25/12 at 10:00 a.m., the director of nursing (DON), Employee #17, was asked to locate any physician's progress notes or evidence of physician visits for Resident #78. During an interview, on 01/25/12 at 11:25 a.m., the DON confirmed there were no physician's progress notes or evidence of any visits to Resident #78 since his admission to the facility on [DATE]. Required visits should have been made the first part of December 2011 and January 2012. b) Resident #29 Medical record review, on 01/24/11, discovered this resident had been seen by the physician on August 31, 2011. The resident was later seen by the physician's assistant on 10/19/11, but there was no evidence found reflecting the physician had acknowledged this visit by co-signing the progress note. There was no evidence to reflect the resident had been seen every sixty (60) days by the physician as required. This finding was presented to Employee #150 (administrator) on 01/03/12 at 10:45 a.m. c) Resident #55 review of the resident's medical record revealed [REDACTED].#55 on 09/20/11. The next recorded physician's visit occurred on 01/12/12. On 01/25/12 at 3:39 p.m., a licensed practical nurse (LPN), Employee #115, reviewed the nurses' notes and the physician progress notes [REDACTED]. This employee also agreed the physician had not made his visits within the required sixty (60) days. d) Resident #13 A review of the medical record of Resident #13 revealed he had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's progress notes indicated a visit had been made by the physician on 08/31/11. There was a partial note written on 10/19/11, that was unsigned, but appeared to be by the physician. There were entries by the physician extender on 09/16/11, and 10/05/11 which had been countersigned by the physician. There was no evidence in the record that the physician had visited the resident except on 8/31/11, and possibly on 10/19/11. This was verified by Nurse #151 who reviewed the record, including the nurses' notes, at 12:30 p.m. on 01/30/12. She also verified, by reviewing other records, the physician's last visit to the unit had been on 12/19/12, but stated he probably did not see all the residents on that visit. e) Resident #49 On 01/25/12, at approximately 1:00 p.m., the medical record review for Resident #49 revealed a [AGE] year-old female with a [DIAGNOSES REDACTED].#5) had made visits on 06/15/11, 08/31/11, and 09/08/11. A family nurse practitioner student (Employee #132) had visited the resident on 10/05/11 and 10/19/11. There was no further documentation to show the resident's physician or family nurse practitioner had seen the resident since 10/19/11. On 01/25/12, at approximately 1:30 p.m., Employee #133 (licensed practical nurse) indicated a flag was placed in the chart for the physician to sign off on the student nurse practitioner's progress note. However, he had not signed these notes. The LPN assisted in a review of the medical record and could not locate any further documentation related to physician's visits.",2016-02-01
9029,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,441,F,0,1,EZVZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's policies and procedures for infection control and isolation for residents with infections, observations of residents with infections, and staff interviews, the facility failed to develop and implement an effective infection control program to prevent the potential spread of infections in the facility. The facility's policies and procedures were not consistently implemented to prevent the spread of infectious organisms. The facility did not maintain a record of all residents with infection, including the infectious organism found and / or the type of isolation precaution to be used. The number of residents at the facility with facility-acquired (nosocomial) infections had increased. There was no evidence the facility had investigated this increase in nosocomial infections for possible causative factors or modes of transmission, in order to implement measures in an attempt to prevent nosocomial infections. The absence of an effective infection control program placed all residents residing in the facility at risk of acquiring a nosocomial infection. Facility census: 70. Findings include: a) Infection Control Program Review of the facility's infection control policies and procedures revealed the policies were not consistently implemented. The infection control policy stated preventative surveillance and control would be done on-going. It also stated a tally sheet for listing all infections according to units would be part of the record keeping. Additionally, the infection control nurse was to report to the infection control committee, all reports of nosocomial infections for their review and recommendations and / or corrective actions to be taken as necessary. Components of the infection control policy stated the (infection control nurse) would use surveillance forms to identify the location of the resident, date of admission and onset of the infection, the type of infection and the cultures taken, and the results if known, and any antibiotics administered. 1) Resident #70 This resident had a urine culture collected on 01/18/12. The results from the urine culture were received and signed by Employee #47 (infection control nurse) on 01/22/12. Review of the infection control nurse's file, on 01/25/12, found a laboratory result for Resident #70 which stated he had two (2) organisms present in his urine. Result 1 of the urine culture was listed as Pseudomonas aeruginosa with greater than 100,000 colony forming units. Result 2 of the urine culture showed growth of [MEDICATION NAME]-Resistant [MEDICATION NAME] (VRE) greater than 100,000 colony forming units. (Colony counts of greater than 100,000 are usually considered an infection.) (VRE is a multiple drug resistant organism (MDRO). A review of Resident #70's care plan and physician orders [REDACTED]. This finding was presented to Employee #17, at 1:35 p.m. on 01/25/12. She stated, she had never seen Resident #70's lab results and was unaware he had VRE. She was shown the laboratory results found in the infection control nurse's file, but again stated she had no knowledge of this. According to the facility's policies and procedures, Employee #47 (infection control nurse) was responsible to report any actual or suspected infection and to initiate any appropriate isolation procedure or precaution. The infection control nurse was to take corrective actions whenever gross breaks in techniques occur that require prompt remedial action. Observation of Resident #70, on 01/25/12 at 3:35 p.m., found him lying in bed without a brief on to contain the urine. (His Foley catheter had been discontinued on 01/18/12.) A soiled brief was on the resident's geri chair beside of his bed. Two (2) confidential staff members were present in the room and Employee #17 (the director of nursing). The director of nursing (Employee #17) said she would change his orders to have a brief placed on the resident. The two (2) confidential staff members stated they did not know he was under any special precautions and verified that one (1) of them had placed the soiled brief in the geri chair. ====== In an interview with Employee #47 (infection control nurse), on 01/25/12 at 9:29 a.m., she stated she had not Communicated the health status of Resident #70 to other staff members. She verified she did not separate the infections in the hospital from the nursing facility, she did not track the organisms, and the infections were broken by infection, not by organism. She was then asked whether she knew how many E-Coli infections she had on the two (2) nursing units during September and October. She responded, No. During a review of the facility's staffing scheduled, on 01/25/12, it was discovered the facility had seven (7) staff members call in on one (1) day. Employee #17 (director of nursing) was asked why there were so many call-ins. She stated, Oh, that's when we had the virus. Review of the infection control program data found no evidence there had been a virus present in the facility. Employee #17 provided a list of twenty (20) residents with symptoms of the virus including nausea, vomiting, and diarrhea. On 01/30/12, at 10:42 a.m., Employee #47 (infection control nurse) was interviewed. She was asked whether she could provide a line listing of the residents with signs and symptoms of the virus. She said, No, I did not keep a list, I don't know which residents had the virus. She further stated, No one in the nursing home part was cultured, I did not report it to the health department, but normally I would. She was also asked whether she kept a tracking device (a map) identifying where the residents with infections were and where the source of the infection may have started. She stated, No. These findings were discussed with Employee #150 (administrator) at 10:15 a.m. on 01/31/12.",2016-02-01
9030,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,465,F,0,1,EZVZ11,"Based on observation and staff interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Items were found stored directly on the floor. This had the potential to result in contamination of the items, as well as inhibiting cleaning beneath the stored items. Ceiling tiles were missing which resulted in wiring and pipes being exposed. The hopper was visibly soiled. Items were stored in close proximity to the hopper with nothing to prevent them from being splashed and soiled. Boxes were stored too close to a breaker box. Heating units were found to be missing controls and covers which had the potential to pose a risk of injury. This had the potential to affect all residents residing in the facility at this time. Facility census: 70. Findings include: a) Unit 2 1) On 01/23/12 at 12:40 p.m., observation revealed Unit 2's shower room had missing ceiling tiles. Pipes and wiring were exposed. 2) The storage room had multiple bags of clothing and bolsters stored directly on the floor. An intravenous (IV) pump was lying in the floor. 3) At 12:45 p.m., on this same day, observation revealed the biohazard room had boxes of yellow bags stored on the floor. The hopper had brown debris around the rim and multiple yellow colored splash marks. An uncovered cart containing pillows and cushions was stored next to the hopper. A picture and bulletin board were on the floor. 4) On 01/25/12 at 11:10 a.m., observation of the resident kitchen, on NFS 2, revealed the coffee pot and coffee dispenser were on a cabinet with a pressed wood top. The top contained multiple spill marks and was warped. The microwave had multiple splatters on the inside. The refrigerator had spills and debris on the shelves and the door. A two burner hot plate had brown debris around the burners. 5) On 01/25/12 at 11:20 a.m., the director of nursing (DON - Employee #17), was shown the areas on Unit 2 and agreed with all of the findings on this unit. On 01/25/12 at approximately 12:00 p.m., the administrator (Employee #150) was informed of the these findings. b) Unit 1 1) At 1:15 p.m. on 01/23/12, observations on Unit 1 revealed a shower curtain rod and towel bar were on the floor of the main shower room. There were boxes and open packages of adult briefs stored in an alcove in the hallway. 2) On 01/25/12 at 2:00 p.m., the storage area on Unit 1 was observed accompanied by the maintenance director (Employee #39). Boxes of adult briefs were stored on a pallet in front of a breaker box. Employee #39 agreed there should be nothing stored within three (3) feet of the breaker box. (The NEC (National Electric Code) requires breaker boxes be kept clear for at least 3 feet square.) 3) Heaters in various resident rooms were found to have no covers over controls which necessitated sticking a hand down in the opening to operate the controls. 4) On 01/26/12 at approximately 11:30 a.m., observation revealed the above issues had been corrected except for the covers on the heating units.",2016-02-01
9031,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,492,D,0,1,EZVZ11,"Based on a review of the resident trust account information, and staff interview, the facility failed to ensure they were in compliance with all state, Federal, and local laws. A review of 64 CSR 13 Title 64 Legislative Rules, West Virginia Division of Health Series 13 Nursing Home Licensure Rule, revealed the facility had violated section 4.10.g.1.I of the rule. The facility allowed the long term care director (Employee #150) to serve as conservator for one (1) of seventy (70) residents. In addition, the facility failed to complete incident reports as mandated by state law when (2) residents experienced falls. Resident identifiers: #26, #78 and #27. Facility census: 70. Findings include: a) Resident #26 A review of the resident trust account information, on 01/24/12, at approximately 1:00 p.m., revealed Resident #26 had a balance of $2,178.47 in her personal funds account. The long term care director (Employee #150) indicated the resident had recently received money from a bank account the resident had not had access to before. She indicated she was working with the resident and family to spend the money in order for the resident to remain eligible for Medicaid benefits. The director commented she served as conservator for this resident. She provided a copy of the court order, dated 08/18/11, which gave her the legal authority to represent the resident as conservator. The long term care director said she was reluctant to take on the role as conservator for Resident #26, but the resident had no family or friends willing to serve in that capacity. She indicated she and her attorney had felt this could be a potential conflict of interest, but had gone along with the judge's decision. A review of the West Virginia State Nursing Home Licensure Rule section 4.10.g.1.I revealed the following An employee of a nursing home, or a person or his or her spouse having a financial interest in the nursing home, shall not serve as a resident's legal representative unless the employee or person is related to the resident within the degree of consanguinity of second cousin or unless the nursing home has been named temporary legal representative payee. On 01/25/12, at approximately 1:00 p.m., the long term care director was informed she could not serve as conservator for Resident #26 as it was prohibited by the nursing home licensure rule. She indicated she would contact the local adult protective services unit as well as the county sheriff's department for assistance in the matter. b) Resident #78 Review of the medical record found Resident #78 had fallen on 01/20/12. The resident was found sitting on his knees in front of his bed. Review of the incident and accidents report found no incident report for this resident. During an interview on 01/24/12 at 11:25 a.m., Employee #17 (director of nursing) , stated, no incident report could be found for the fall on 01/20/12 documented in nurse's notes. c) Resident #27 Review of the medical record found Resident #27 had sustained a fall in her room on 12/29/11. When a copy of the incident report was requested, on 01/24/12 at 11:35 a.m., Employee #17 stated, I cannot find an incident report. She further, stated she did not remember discussing this resident having a fall in the morning meetings held by the facility.",2016-02-01
9032,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,520,F,0,1,EZVZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview the facility failed to maintain an effective Quality Assessment and Assurance Committee by: 1. not recognizing areas of concern that were widespread and had the potential to increase, if not rectified, as necessary to be taken to the committee; 2. not developing a plan of action to solve these concerns; and 3. not implementing a plan of correction. This had the potential to effect all residents in the facility. Facility census 70. Findings include: a) During the resurvey there were four deficient practices that were widespread enough and/or had been present in the facility long enough that they should have been identified by the quality assessment and assurance (QAA) committee and plans of action implemented to correct these deficiencies. These were: 1. There were several instances that one physicians were not signing orders in a timely manner and/or making resident visits as required (see F386 / F387). This same situation was cited during the previous survey. It was apparent that the Plan of Correction completed at that time was no longer effective. During an interview with the administrator at 8:30 a.m. on 01/31/12, she acknowledged that she was aware that physician's visits were not being made in a timely manner and/or that physician's orders [REDACTED]. These deficiencies were also acknowledged by the director of nurses (DON) at 2:00 p.m. on 01/30/12 and by Nurse #151 at 12:30 p.m. on 01/30/12. 2. A review of the Infection Control Program revealed that the tracking of infectious disease in the facility did not identify the organism nor the location of the resident with an infection (see F441). The infection control nurse (Nurse #47), when interviewed on 01/26/12, could not state or produce documentation of the names and locations of active isolations and stated that she did not know what organisms had been identified as this was not part of her surveillance. When asked at 10:00 a.m. on 01/30/12, what was reported to the QAA committee she produced a quarterly report which was contained on one page and included only numbers of infections with no attempt at identifying patterns or causes. This was not in compliance with the Infection Control Policies approved by the QAA committee, but the committee had not identified that the policy was not being followed and/or that effective tracking was being done. In December 2011 and January 2012 there had been an outbreak of 20 residents with nausea, vomiting, and diarrhea. When interviewed at 10:40 a.m. on 01/30/12, Nurse #47 stated that she had informed the DON and the administrator, but admitted that she had not notified the County Health Department or kept a list of the residents. During an interview with the DON on 01/30/12, she stated that she was not aware that the infection control nurse was not reviewing the cause and location of infections. She admitted that she had not read closely the report to the QAA committee. 3. Multiple environmental issues were observed during the survey on both long term care units and were pointed out to both the DON and the administrator (see F252, F253, F323, and F371). They expressed no surprise at the findings and stated that they would try to rectify the deficiencies, but when asked if these problems had been taken to the QAA committee, the answer was no. 4. There was no process in place reflecting that the facility acted quickly and appropriately to concerns/complaints/grievances received from family members and/or residents, either individually or at Resident Council meetings (see F244). During an interview with the Social Worker at 11:00 a.m. on 01/25/12, she stated that when a complaint was received she or another employee investigated it and reported back to the complainant, but acknowledged that she could not show evidence of this as there was no records maintained. These actions were reported to the administrator when they happened, but there was no tracking or audit of the incidents. In interviews with QAA members, they agreed that reportable allegations and incident reports were summarized for the committee, but grievances or complaints were not. During interviews with the administrator at 8:30 a.m. on 01/31/12; the director of nurses at 9:30 a.m. on 01/31/12; the Social Worker at 3:00 p.m. on 01/30/12, and the Activities Director at 10:30 a.m. on 01/26/12, the only issues that any of them could recall being presently addressed by the QAA committee was falls. The administrator stated that QAA met quarterly, but deferred questions about departmental reporting and how long term care was integrated into the hospital - wide program to the DON, as she stated that she was the liaison to QAA. The DON stated that QAA for long - term care met monthly and when necessary she relayed concerns to the quarterly hospital - wide meeting. The Social Worker stated that there was a monthly meeting, but that all department heads did not come each time. She wasn't sure how they rotated, but knew they did. When asked the purpose of the QAA committee, the usual answer was reporting and no one knew of any problems with a plan of correction underway at the present time.",2016-02-01
9863,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-08-23,225,D,1,0,XBKB11,". Based upon record review, review of the facility's complaint files, review of incident reports, and staff interview, the facility failed to ensure that an alleged violation involving mistreatment, neglect, or abuse was reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). This was found for one (1) of six (6) documented complaints received by the facility during 2012. Resident identifier: #23. Facility census: 65. Findings include: a) Resident #23 The facility's complaint files were reviewed on 08/20/12 at 2:50 p.m. There was a documented complaint dated 04/12/12. The daughter of Resident #23 came to the nurses' station at 7:45 p.m. She had found her mother sitting in the dark in her room in her wheelchair soaked in urine, and her prosthetic sleeve was dirty and had a foul odor. When she asked for disinfectant to clean it, she was given a can of stainless steel cleaner. Facility documentation was made on an incident report form. Under the sections ""Contributing Factors"" and ""Prevention"" was recorded ""Resident should have been put to bed once the CNA (nursing assistant) put resident in the room. (Local church group was wanting staff to take residents to church on NCFII (one of two separated units in the facility). It was also shift change. Having staffing problems."" The witness statement that was completed by the nursing assistant providing care included the statement ""The whole time, (resident's daughter) is telling us 'this is neglect and abuse. . . .'"" The incident report completed by the nurse under the section ""Type of Incident"" stated ""Abuse/Neglect"". There was no indication the allegation had been reported to any outside agencies. There was no record of reporting in the facility's abuse/neglect reporting logs when that information was reviewed on 8/20/12 at 1:50 p.m. b) The social worker, Employee #63, who assumed her duties at the facility on 07/09/12, was interviewed on 08/21/12 at 4:10 p.m. She confirmed the allegation did not appear to have been reported as required. .",2015-08-01
9864,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-08-23,244,E,1,0,XBKB11,". Based upon review of facility documents, resident interview, and staff interview, the facility failed to act upon the grievances and recommendations of residents regarding staffing and lack of timely response to call lights. This was also cited during the annual survey of 01/31/12, and had the potential to affect more than an isolated number of residents. Facility census: 65. Findings include: a) Review of the resident council meeting minutes, on 8/20/12 at 2:00 p.m., found that during the meeting of 06/28/12, four (4) residents expressed concerns about staff response to call lights. The minutes (typed as written) stated: ""Call Lights and Call Response Time 20 minute wait and Bells being turned off."" This concern was then found included on a complaint form which was also dated 06/28/12. Under the ""Report of complaint investigation"" section, the former director of social services had documented (typed as written): ""General consensus that the call bells were not always answered promptly However no specific dates or times given Call light/bell study - all shifts in various rooms to determine length of response and develop system for faster results/response times"". The section ""Was complaint valid?"" was checked ""yes"". The results of the Call light/bell study were requested from the administrator, Employee #64, on 8/22/12 at 3:00 p.m. On 08/23/12 at 8:08 a.m., the administrator stated that no audit was completed and no response was ever made to the residents. b) Resident #26, who was one of the residents that expressed concerns during the Resident Council meeting of 06/28/12, was interviewed on 08/22/12 at 3:20 p.m. She confirmed that call light response continued to be a problem due to insufficient staff, stating ""No, there is absolutely not enough. If they are busy with someone else, you can wait a half hour or even an hour for toileting, getting in and out of bed, and so forth. They are all very nice to us, and do their best, but they can't keep up with it. Anybody you ask will tell you that except for the big bosses."" .",2015-08-01
9865,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-08-23,323,G,1,0,XBKB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based upon record review, staff interview, and observation, the facility failed to provide adequate supervision to prevent accidents and ensure the resident environment remained as free of accident hazards as possible. This resulted in falls and injury to one (1) resident. Two (2) of nine (9) residents on the sample were affected. Facility census: 65. (This was also cited during the annual survey of 01/31/12) Findings include: a) Resident #28 This [AGE] year old lady was readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was found to have had a fall with a fracture on 03/23/12, a second fall on 06/08/12, and another fall with a fracture on 07/24/12. Her record was reviewed on 08/20/12 at 10:35 a.m. She had been assessed as being at risk for falls since her admission. Her comprehensive minimum data set (MDS) assessment, of 06/07/12, indicated she was not steady, only able to stabilize with staff assistance for moving from a seated to a standing position, walking, turning around, moving on and off of the toilet, and surface-to-surface transfers. She was assessed as being at risk for falls due to poor balance, psychotropic drug use, and poor safety awareness related to her dementia. She also had a built-up shoe for her right foot due to the right leg being shorter than her left. A review of her care plan found there was an intervention in place as early as 03/17/12 that stated ""Do not leave alone in bathroom, activity, or hairdressing rooms."" The KARDEX, or specific instructions for the nursing assistants concerning individualized care to be provided for Resident #28, contained the statement under the ""comments"" section: ""Resident is not to be left alone in BR (bathroom)."" The incident report of 03/23/12, for her fall with fracture, indicated she fell when left unattended by staff. Under the ""Prevention"" section was documented: ""Two staff members should've remained with the resident until resident was seated in the wheelchair."" The incident report for her fall with fracture of 07/24/12, indicated she fell again when left unattended by staff. Under the ""Contributing Factors"" section was documented ""Alzheimer's - Resident in Bathroom - didn't ring when finished CNA (Certified Nursing Assistant) went to next room to get assist with transfer."" An interview was conducted with Director of Nursing (DON), Employee #2, on 08/21/12 at 10:30 a.m. She acknowledged the intervention ""do not leave alone in bathroom"" was care planned as early as 03/17/12, due to the resident's poor balance, psychotropic drug use, and poor safety awareness related to dementia, all of which were continued concerns. She stated that although the intervention was developed for the interdisciplinary plan of care, it had never been added to the KARDEX care instructions until after the fall and fracture of 07/24/12. It was added so the nursing assistants would know not to leave her alone. She stated there was not sufficient staff on a consistent basis to permit someone to stay with every resident who might need such supervision for safety. b) Resident #48 This resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. His medical record was reviewed on 08/20/12 at 2:30 p.m. He experienced a fall on 04/07/12 and again on 08/15/12. He was assessed as being at high risk for falls upon his admission on 01/08/11 and on all subsequent assessments. He was determined to be at risk for falls due to his lack of balance, use of medications, and dementia. He had a care plan in place for risk for injury from falls. On 08/15/12, he fell while ambulating from his bed to the bedside commode. After the fall, recommendations were made by nursing and physical therapy to discontinue his scheduled toileting program and instead check, change, and toilet him as needed. There was also a recommendation to remove the bedside commode from the room for safety purposes and put a urinal at bedside. Observations throughout the survey found the bedside commode beside his bed all day on Monday, 08/20/12, Tuesday 08/21/12 and Wednesday 08/22/12. The intervention to remove the bedside commode from the room had not been added to the KARDEX, or specific instructions for the nursing assistants concerning individualized care to be provided for resident #48, which still contained a checkmark beside""Bedside Commode"". Registered nurse (RN), Employee #58 was interviewed on 8/21/12 at 12:10 p.m. She acknowledged that the interdisciplinary decision to remove the bedside commode for safety reasons on 08/16/12 had not been implemented, nor had it been added to the KARDEX care instructions for the direct care staff. .",2015-08-01
9866,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-08-23,353,E,1,0,XBKB11,". Based upon record review, resident interview, confidential staff interviews, and staff interview, the facility failed to ensure adequate staffing levels across all shifts to meet the needs of dependent residents such as assisting the residents to the bathroom and answering call lights in a timely manner. This had the potential to affect all residents who were dependent or required staff assistance. Facility census: 65. Findings include: a) Review of the facility complaint files on 8/20/12 at 2:50 p.m. found a documented complaint dated 04/12/12. The daughter of Resident #23 came to the nursing station at 7:45 p.m. She had found her mother sitting in the dark in her room in her wheelchair soaked in urine. Facility documentation was made on an incident report. Under the sections ""Contributing Factors"" and ""Prevention"" was recorded ""Resident should have been put to bed once the CNA put resident in the room. (Local church group was wanting staff to take residents to church on NCFII (one of two separated units in the facility). It was also shift change. Having staffing problems."" b) Review of facility resident council meeting minutes, on 8/20/12 at 2:00 p.m., found that during the meeting of 06/28/12, four (4) residents had expressed concerns about staff response to call lights. The minutes (typed as written) stated: ""Call Lights and Call Response Time 20 minute wait and Bells being turned off."" This concern was then found included on a complaint form which was also dated 6/28/12. Under the ""Report of complaint investigation"" section, the former director of social services had documented (typed as written): General consensus that the call bells were not always answered promptly However no specific dates or times given Call light/bell study - all shifts in various rooms to determine length of response and develop system for faster results/response times. The section ""Was complaint valid?"" was checked ""yes"". The results of the Call light/bell study were requested from the administrator, Employee #64 on 8/22/12 at 3:00 p.m. On 8/23/12 at 8:08 a.m., the administrator stated that no audit had been completed and no response was ever made to the residents. c) Two (2) nursing assistants were interviewed. Both expressed that they would only speak with the promise of confidentiality. Nursing assistant ""a"" stated that nursing assistants are being required to document care as completed when in fact it cannot all be done because there is not sufficient staff. Nursing assistant ""b"" stated that there was not sufficient staff to provide needed care and that ""someone could fall and we wouldn't even know it."" d) The director of nursing, Employee #2, was interviewed on 08/21/12. She stated there was not sufficient staff to permit someone to stay with every resident who needed supervision for safety. This comment was made during an interview about Resident #28, who had been left unattended in the bathroom, fallen, and sustained a fracture on 07/24/12. The resident had been assessed as requiring staff to be in attendance when on the toilet. e) The facility consists of two (2) units separated by two floors and it is not logistically possible for nursing assistants working on one unit to respond to lend assistance on the other when it is needed. Forty-six (46) of the facility's seventy-six (76) beds are on one unit, while the thirty (30) remaining beds are on another. It requires walking through an underground tunnel, and the taking an elevator or walking up two (2) flights of stairs to go from nursing care unit one to nursing care unit two. Review of the resident census and condition of residents (CMS-672) information, provided by the facility on 08/20/12, found that of the current census of 65, only 2 were independent for bathing, 8 were independent for dressing, 21 were independent for transferring, and 13 were independent for toilet use. Forty-two (42) were listed as independent for eating. All of the other residents either required the assistance of one or two staff for those tasks, or were completely dependent upon staff to provide that care. Information was requested from Employee #2 on 08/22/12 regarding residents that usually or always required 2 nursing assistants to provide or assist with bathing, dressing, transferring, toilet use, or eating. It was found that 12 of the residents on Unit one always required the assistance of 2 staff to provide care, and 4 often required the assistance of 2 staff to provide care. It was found that 8 of the residents on Unit 2 always require the assistance of 2 staff, and 1 often required the assistance of 2 staff. f) The following residents were identified by the facility a interviewable. They were asked if the facility had enough staff to provide care in a timely manner to all the residents. Resident #1 was interviewed on 8/22/12 at 2:20 p.m. She stated there is not enough help. Sometimes she had to wait a long time for help, and sometimes it came too late. She said that ""All the girls are always stressed out here because they can't keep up with it."" Resident #26 was interviewed on 08/22/12 at 3:20 p.m. She stated ""No, there is absolutely not enough. If they are busy with someone else, you can wait a half hour or even an hour for toileting, getting in and out of bed, and so forth. They are all very nice to us, and do their best, but they can't keep up with it. Anybody you ask will tell you that except for the big bosses."" Resident #62 was interviewed on 08/22/12 at 3:45 p.m. She said ""Definitely not enough staff. Sometimes you have to wait an awful long time, especially if you're on the toilet. I have sat in that toilet seat for almost an hour. I think something should be done about it."" Resident #49 was interviewed on 08/22/12 at 4:00 p.m. He stated ""They are burning the candle at both ends. They get worn out. They do their best, but there is no way they can keep up with it all."" Resident #22 was interviewed on 08/22/12 at 4:12 p.m. He replied ""There is not enough at all. They do the best they can, but they cannot keep up. Lots of people need two staff to help them and so there's no one available when you need them. It is not unusual to wait one half to an hour when you ring the call bell. That light could be something minor like wanting some crackers like I'm eating here, or you could be choking to death and unable to tell them what you want. It is a big problem here."" .",2015-08-01
9867,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-08-23,386,E,1,0,XBKB11,". Based upon record review and staff interview, the facility failed to ensure a physician reviewed the residents' care at the time of each visit by signing and dating all orders in a timely manner as required. This was found for four (4) of six (6) residents whose records were reviewed This had the potential to affect more than an isolated number of residents. Facility census: 65. (This was also cited during the annual survey of 01/31/12.) Findings include: a) Resident #2 The medical record of Resident #2 was reviewed on 08/22/12 at 8:00 a.m. She was seen by a physician on 07/16/12, but orders remained unsigned going back to 07/01/12. b) Resident #65 The medical record was reviewed on 08/22/12 at 8:10 a.m. She was seen by a physician on 07/16/12, but orders remain unsigned going back to 07/1/12. c) Resident #54 The medical record was reviewed on 08/22/12 at 8:18 a.m. There were unsigned orders going back as far as 06/01/12. d) Resident #46 The medical record was reviewed on 08/22/12 at 8:35 a.m. There were unsigned orders as far back as 03/01/12. e) The medical records coordinator, Employee #99, was interviewed on 08/22/12 at 9:42 a.m. She stated the plan of correction for the annual survey of 01/31/12 was that the Administrator conducted a monthly audit by the first Tuesday of every month for physicians' compliance and then gave the results to her for letters to be sent to physicians who were non-compliant. The physicians were to have five (5) days to complete the required documentation, or would face possible suspension by the hospital's Long Term Care Committee. She stated she had not received an audit since May 2012, and the last letter she sent to physicians was on 06/13/12. Prior to that, the last audit she received was in January 2012, which resulted in a letter being sent to physicians on 02/23/12. She acknowledged there were continued problems with orders not being signed in a timely manner. f) The administrator, Employee #64, was interviewed on 08/23/12 at 9:00 a.m. She stated she had hand delivered letters to non-compliant physicians herself up until March, 2012. Copies were provided that required completion by 03/06/12. She acknowledged that the most recent audit that had been used to notify non-compliant physicians was the May 2012 audit, which resulted in the letter of 06/13/12. There was no evidence of any follow-up or physician notifications after 06/13/12. .",2015-08-01
9868,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-08-23,490,G,1,0,XBKB11,". Based upon record review, resident interview, and staff interview, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evident from a failure to correct deficient practices identified on the annual survey of 01/31/12. The facility had failed to complete all elements of the approved plan of correction, or implemented other corrective actions, in the areas of preventing injury from accidents, which was found for two (2) of nine (9) residents reviewed; responding and acting upon group grievances, which was found for one (1) complaint and had the potential to affect more than an isolated number of residents; and ensuring that physician's orders were signed in a timely manner, which was found for four (4) of six (6) records reviewed. All residents had the potential to be affected. Facility census: 65. Findings include: a) The facility was cited for failure to provide adequate supervision to prevent accidents for Resident #28. The resident was left alone while on the toilet which resulted in a fall with a fracture. Additionally, the facility had not ensured the resident environment remained as free of accident hazards as possible, which was found for Resident #48. A bedside commode that had been identified as an accident hazard was observed to remain in the resident's room throughout the survey. The facility was cited for the same deficient practices during the annual survey ending 01/31/12, and had submitted an approved plan of correction designed to address staff responsiveness to resident's needs and environmental hazards by 03/31/12. (See F323) b) The facility failed to respond to, and act upon, group grievances. Members of the resident council had expressed concern with call lights not being answered in a timely manner during their meeting of 06/28/12. The facility was to conduct an audit in an effort to investigate the concern, but this was never done. There was never any response given to the council regarding the issue. The facility was cited for the same deficient practice during the annual survey ending 01/31/12. A plan of correction had been submitted that was designed to address the issue by 03/08/12. The plan included tracking and monitoring of all grievances, revising the facility's policies and procedures, and implementing two (2) new forms. (See F244) c) The facility failed to ensure physician's orders were signed in a timely manner. One resident was found to have unsigned orders for March 2012. The facility was cited for the same deficient practice during the annual survey ending 01/31/12. A plan of correction had been submitted and approved that was designed to address the issue by 03/05/12. Interviews with the medical records coordinator, Employee #99 and administrator, Employee #64, found that many of the elements of the proposed corrective action had not been completed as pledged. (See F386) .",2015-08-01
9869,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-08-23,520,G,1,0,XBKB11,". Based upon observation, record review, staff interview, and resident interview, the facility failed to maintain a quality assessment and assurance committee that developed and implemented appropriate plans of action to correct identified quality deficiencies in the areas of preventing injury from accidents, which was found for two (2) of nine (9) residents reviewed; responding and acting upon group grievances, which was found for one (1) complaint and had the potential to affect more than an isolated number of residents; and ensuring that physician's orders were signed in a timely manner, which was found for four (4) of six (6) records reviewed. These issues had the potential to affect all residents. Facility census: 65. Findings include: a) The facility was cited for failure to provide adequate supervision to prevent accidents for Resident #28. The resident was left alone while on the toilet which resulted in a fall with a fracture. Additionally, the facility had not ensured the resident environment remained as free of accident hazards as possible, which was found for Resident #48. A bedside commode that had been identified as an accident hazard was observed to remain in the resident's room throughout the survey. The facility was cited for the same deficient practices during the annual survey ending 01/31/12, and had submitted an approved plan of correction designed to address staff responsiveness to resident's needs and environmental hazards by 03/31/12. (See F323) b) The facility failed to respond to, and act upon, group grievances. Members of the resident council had expressed concern with call lights not being answered in a timely manner during their meeting of 06/28/12. The facility was to conduct an audit in an effort to investigate the concern, but this was never done. There was never any response given to the council regarding the issue. The facility was cited for the same deficient practice during the annual survey ending 01/31/12. A plan of correction had been submitted that was designed to address the issue by 03/08/12. The plan included tracking and monitoring of all grievances, revising the facility's policies and procedures, and implementing two (2) new forms. (See F244) c) The facility failed to ensure physician's orders were signed in a timely manner. One resident was found to have unsigned orders for March 2012. The facility was cited for the same deficient practice during the annual survey ending 01/31/12. A plan of correction had been submitted and approved that was designed to address the issue by 03/05/12. Interviews with the medical records coordinator, Employee #99 and administrator, Employee #64, found that many of the elements of the proposed corrective action had not been completed as pledged. (See F386) .",2015-08-01
9870,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-11-07,465,B,1,0,XBKB12,". Based on observation and staff interview, the facility failed to provide a safe and sanitary environment for the residents, staff, and the public in the long term care area located on the second floor of the main hospital building, by failing to keep the perimeters of the floors in the diet kitchen, the hallways, and the elevators clean and free of debris. This had the potential to affect all who came to this area. Facility census: 66. Findings include: a) During a follow-up tour of NCF II (Nursing Care Facility II is the unit located on the second floor of the main hospital building), at 12:45 p.m. on 11/05/07, the floor of the diet kitchen was observed to be dirty overall and grime around baseboards and pipes (near the ice machine). There were papers and debris, including a wash basin on the floor under the cabinets. The floors along the edges, near the baseboards, both in rooms and hallways were unclean. The thresholds of each room were also in need of cleaning. In the soiled utility room, the metal cabinet under the sink was rusted (completely through in spots). While there were no sterile supplies or supplies for direct resident care, there were new red (infectious waste) bags and other supplies stored there. The elevator tracks were dirty and filled with debris. Employee #67 (RN) was present in the diet kitchen at 1:00 p.m. on 11/06/12, and agreed the floor needed cleaned. The DON was informed shortly after and visited the area on her own. During an interview with the head of housekeeping (Employee #64), at 2:08 p.m. the same day, Employee #64 first stated they had a new employee working on this floor, but had no answer when it was pointed out to her the areas described had grime that was not of recent origin. She stated she would schedule these floors to be stripped and cleaned. .",2015-08-01
9871,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-11-07,253,B,1,0,XBKB12,". Based on observation and staff interview, the facility failed to provide adequate housekeeping to ensure a clean and orderly environment by failing to keep the outer perimeters of the floors, both in the residents' rooms and in the hallways of the nursing unit located on the second floor of the main hospital, clean. This had the potential to affect all residents (24) residing in this location. Facility census: 66. Findings include: a) During the initial tour of NCF II (Nursing Care Facility II is the unit located on the second floor of the main hospital building), at 12:15 p.m. on 11/05/07, the floors along the edges, near the baseboards, both in rooms and hallways were noted to be in need of cleaning. The thresholds of each room were also unclean in appearance. A revisit to NCF II, at 12:45 p.m. on 11/06/12, revealed the floors were still grimy at the edges in both rooms and hallways. These observations were reported to the DON at 1:00 p.m. on 11/06/12, and discussed with the head of housekeeping (Employee #64) at 2:08 p.m. the same day. Employee #64 first stated they had a new employee working on this floor, but had no answer when it was pointed out to her that the areas described had grime that were not of recent origin. She stated she would schedule these floors to be stripped and cleaned. .",2015-08-01
9872,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2014-12-18,282,D,0,1,GZSS12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the [MEDICAL TREATMENT] communication records, and staff interview, the facility failed to follow the care plan for post [MEDICAL TREATMENT] care for one (1) of one (1) sample residents. The facility failed to assess the resident, as indicated in the care plan, upon return to the facility from the [MEDICAL TREATMENT] unit. Resident identifier: #65. Facility census: 58. Findings include: a) Resident #65 A review of the care plan for Resident #65, on 12/16/14 at 10:43 a.m., revealed the following interventions, dated 11/20/14: ""Upon arriving to facility from [MEDICAL TREATMENT] check that dressing to access site dry and intact, check for presence of thrill and bruit, check for presence of a pulse in the affected arm, present of [MEDICAL CONDITION] of the hand, and capillary refill of fingers, check vital signs and weight."" On 12/16/14 at 10:57 a.m., a review of the nurses' notes, typed as written, revealed the following: - ""11/28/14 at 16:30 (4:30 p.m.) Returned to the facility safely at 16:30 Pm.No N/V (nausea and vomiting). BP (blood pressure) 142/70 mmHg (millimeters of mercury), Temp (temperature) 98.4, P (pulse) 70 and R (respirations) 20. And Post-WT (weight) [MEDICAL TREATMENT] was 110.6 lbs (pounds), and 1.9 lbs withdrawn.Dsg (dressing) to [MEDICAL TREATMENT] site to L)UA (left upper arm) patent, dry and no s/s (signs/symptoms) of infection.Bruit and thrill present.No C/O (complaints) pain or discomfort.resting in bed quietly. - 12/01/14 at 16:00 (4:00 p.m.) resident returned safely at this time. VS:BP130/66 mmhg, Temp [MEDICATION NAME] and [MEDICATION NAME] taken at 2pm at [MEDICAL TREATMENT].No N/V. The [MEDICAL TREATMENT] port site to LUA covered w/ (with) pressure dsg (dressing), and patent, dry. No redness or bleeding.Bruit and thrill positive.Resting in bed quietly. Pre WT was 108.7 lbs and post-Wt was 102.8 lbs, 5.7 lbs withdrawn by [MEDICAL TREATMENT]. - 12/03/14 16:30 (4:30 p.m.) Returned from [MEDICAL TREATMENT] with communication book. No bleeding from insertion site. Thrill present. No signs of infection. Alert and oriented."" - 12/05/14 No assessment completed upon return from [MEDICAL TREATMENT]. "" -12/08/14 Returned from dilaysis (sic) safely to the facility. VS:BP 130/80 mmHg. Temp98.3, P80 and R20.Post-WT was 103.7 lbs.Shunt site to LUA patent, dsg dry and intact. No redness or bleeding. No [MEDICAL CONDITION] to BUE (both upper extremities) and BLE (both lower extremities).No N/V. Eating a dinner. -12/10/14 at 17:00 (5:00 p.m.) returned to the facility safely at this time. VSS, and no C/O pain or discomfort.No N/V.[MEDICAL TREATMENT] port site to l)UA covered w/ pressure dsg, and patent, no bleeding. Bruit and thrill positive. No redness. No [MEDICAL CONDITION] to BUE and BLE. Resting in bed quietly. Post-WT was 113.2 lbs. According to the record,pre-WT was 108.0 lbs, and amt (amount) withdrawn wt was not clear. -12/12/14 at 17:00 (5:00 p.m.) Resident returned from the [MEDICAL TREATMENT] to the facility safely at this time. No N/V, and [MEDICATION NAME] mg PO (orally) and [MEDICATION NAME] 4 mg PO were taken at the [MEDICAL TREATMENT] prior to the ride back. VS:BP 150/68 mmHg,T 98.7 oral, P72, P20.No SOB (shortness of breath) or distress.No C/O pain or discomfort. Pressure dsg to l)UA patent and dry, no bleeding. No redness to the area and No s/s of infection.Bruit and thrill positive.No [MEDICAL CONDITION] present to BUE and BLE.Amt of fluid withdrawn not positive.No [MEDICAL CONDITION] present to BUE and Ble.Amt of fluid withdrawn not determined due to inconsistency of WT measured.Resting quietly. - 12/15/14 at 17:35 (5:35 p.m.) Positive bruit noted in left arm. No bleeding noted. No redness noted. [MEDICAL TREATMENT] communication book returned with resident. Reviewed per this nurse. No changes/issues noted."" The post [MEDICAL TREATMENT] assessments did not contain a check for presence of a pulse in the affected arm, present of [MEDICAL CONDITION] of the hand, and capillary refill of fingers. On 12/16/14 at 1:00 p.m., after reviewing the nurses' notes, the director of nursing (DON) agreed the care plan had not been followed and a post [MEDICAL TREATMENT] assessment had not been completed on 12/05/14. .",2015-08-01
10580,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,152,D,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the legal surrogate, of one (1) of thirteen (13) residents reviewed, exercised the resident's rights in accordance with State law. Resident #24 had designated a medical power of attorney representative (MPOA) to make health care decisions for her in the event she should lack the capacity to do so. The MPOA was making health care decisions on the resident's behalf, although there was no determination of incapacity in her record to reflect she was incapable of making these decisions for herself. Resident identifier: #24. Facility census: 60. Findings include: a) Resident #24 The medical record of Resident #24, when reviewed on 07/27/09, disclosed this [AGE] year old female had been admitted to the facility on [DATE], following hospitalization after a fall resulting in a subdural hematoma and cervical fracture. Review of the resident's admission documents, as well as the physician's orders [REDACTED]. The resident's medical record contained no document stating she herself did not have the capacity to make her own health care decisions. The facility's director of nursing (DON), when interviewed related to these findings on 07/29/09, confirmed that, although the resident was indeed unable physically and mentally to make her own decisions, there was no determination of incapacity completed by the attending physician for this resident. .",2015-01-01
10581,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,279,D,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to develop care plans, for three (3) of fifteen (15) residents reviewed, to reflect each resident's current needs. Resident #56 had experienced a substantial weight gain above her ideal body weight, and this was not reflected in the care plan. Resident #48 was receiving [MEDICAL CONDITION] treatments at an outside facility five (5) days per week, and the plan of care did not mention this. Resident #15 had developed a Stage II pressure ulcer, and this was not reflected in the plan of care. Facility census: 60. Findings include: a) Resident #56 The medical record for Resident #56, when reviewed on 07/28/09, disclosed the resident had been admitted to this facility from another facility on 01/12/09. At the time of admission, the resident was noted to weigh 102 pounds with a height of 62 inches. The initial note completed by the facility's registered dietitian stated her ideal body weight was 110 pounds. Her most recent minimum data set (MDS) assessment, and abbreviated quarterly assessment with an assessment reference date (ARD) of 07/09/09, revealed her weight during the assessment reference period was 119#. The resident's most recent care plan, revised on 07/09/09, stated the resident was ""at nutritional risk related to disease process"". The goal stated, ""Resident will maintain weight."" The interventions determined necessary to address this problem were: ""Monitor intake and provide supplement PRN (as needed). Monitor weight, food and fluid intake. Provide food preferences upon request."" The care plan had not been changed to reflect the resident's surpassing her ideal body weight. b) Resident #48 The medical record of Resident #48, when reviewed on 07/29/09, disclosed a physician's orders [REDACTED].@ 1300 (1:00 pm) last treatment 07/10/09."" The resident's most current care plan, revised on 07/09/09, contained no mention of the resident's [MEDICAL CONDITION]. The facility's administrator, when provided these findings on 07/29/09 at 2:00 p.m., confirmed the care plan made no mention of the [MEDICAL CONDITION] treatments in an outside facility. c) Resident #15 Review of physician's orders [REDACTED]. Review of the facility's Weekly Decubitus Report, dated 06/26/09 to 07/28/09, revealed a Stage II pressure ulcer had been discovered on 06/26/09 and was being treated. Review of the resident's current care plan, dated 06/11/09 to 09/10/09, found it had not been revised to include the development of a Stage II pressure ulcer with interventions developed to promote healing. In an interview on 07/30/09 at 10:00 a.m., the director of nursing (Employee #4) confirmed the care plan had not been revised after the resident developed into a Stage II pressure ulcer. .",2015-01-01
10582,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,280,D,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed, for one (1) of fifteen (15) residents reviewed, to ensure each resident's plan of care was prepared by an interdisciplinary team including all staff involved in the care of the resident and as determined by the needs of the resident. The record record contained two (2) separate care plans, one (1) by facility staff and the other developed by the Hospice Agency contracted to provide care to the residents. Furthermore, the goals of the care plans and interventions to meet those goals were not integrated in a manner to provide the greatest benefit to the resident. Resident identifier: #3. Facility census: 60. Findings include: a) Resident #3 The medical record of Resident #3, when reviewed on 07/29/09 at 3:00 p.m., disclosed this [AGE] year old male had been admitted to the facility on [DATE], and had been admitted to the services of Hospice on 06/11/09 with the terminal [DIAGNOSES REDACTED]. The resident's record contained two (2) separate care plans, one (1) developed by facility staff and another developed by the Hospice agency providing care to the resident. The facility's care plan, dated 07/02/09, recognized problems such as risk of alteration in comfort related to decreased mobility, arthritic joints, compression fracture; risk for impaired communication; risk for impaired skin integrity; etc. The Hospice document entitled ""Interdisciplinary Plan of Care"" recognized similar problems, but the interventions stated by the facility were not integrated with those of the Hospice. Neither plan of care displayed involvement of the other entity in its development.",2015-01-01
10583,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,281,D,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on observation, review of the facility's ""Do not crush list"", and staff interview, it was determined one (1) of three (3) nurses observed (Employee #11) passing medications during the medication observation task failed to provide care for Resident #55 that met current standards of care, by crushing and administering two (2) medications on the list that were not formulated to be crushed. Resident identifier: #55. Facility census: 60. Findings include: a) Resident #55 During the medication pass observation on 07/27/09 at 3:30 p.m., the nurse (Employee #11) was observed preparing the following medications for Resident #55: [MEDICATION NAME] 400 mg, EC ([MEDICATION NAME] coated) Aspirin 81 mg, Senna tab, [MEDICATION NAME] 100 mg, and Vitamin C 500 mg. During the preparation, the nurse crushed all of these medications except [MEDICATION NAME] 100 mg. When this surveyor questioned the nurse which medications were crushed, the nurse stated, ""I crushed everything except the [MEDICATION NAME]."" Review of the facility's ""Do not Crush list"" revealed the [MEDICATION NAME] coated aspirin and [MEDICATION NAME] should not have been crushed. During an interview on 07/29/09 at 10:30 a.m., the director of nursing (DON - Employee #4) confirmed [MEDICATION NAME] coated aspirin and [MEDICATION NAME] should not have been crushed. --- Part II -- Based on record review and staff interview, the facility permitted a nurse to function outside of her scope of practice, by allowing her to order a change in treatment for one (1) of thirteen (13) residents reviewed. Resident identifier: #11. Facility census: 60. Findings include: a) Resident #11 The medical record of Resident #11, when reviewed on 07/28/09, disclosed the resident had been experiencing increased difficulty swallowing, and a swallowing evaluation was completed at 12:35 p.m. on 07/27/09. Following the evaluation, the individual completing the evaluation (unable to read professional title) recommended the resident be ""NPO (nothing by mouth) with alternate method of nutrition / hydration"". When notified at 1300 (1:00 p.m.). the resident's physician gave the following order: ""D/C (discontinue) [MEDICATION NAME], Suction PRN (as needed)."" Later on 07/27/09 at 1815 (06:15 p.m.), a facility nurse had written under the preceding order on a ""physician's orders [REDACTED]. This entry was followed with ""per nursing"" and signed by Employee #27. The DON, when interviewed on 07/29/09 at 10:00 a.m. related to the resident's condition and this finding, stated the resident had not been made NPO by the physician and that deciding to implement a NPO status was not within the scope of practice for a nurse. .",2015-01-01
10584,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,329,D,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, and review of OBRA's (Omnibus Budget Reconciliation Act of 1987) ""Unnecessary Drugs in the Elderly"", the facility failed to ensure the drug regimen of three (3) of thirteen (13) sampled residents was free from unnecessary drugs. Residents #12, #20, and #11 were receiving medications given in excessive doses, for excessive duration, and/or without adequate monitoring. Resident #12 was receiving [MEDICATION NAME], a sedating drug, in excessive doses not recommended for use in the elderly. Resident #20 had received [MEDICATION NAME], a sedating drug, for excessive duration. Resident #11 had received [MEDICATION NAME], an antipsychotic drug, in excessive doses not recommended for the elderly. Resident identifiers: #12, #20, and #11. Facility census: 60. Findings include: a) Resident #12 Medical record review, on 07/28/09, discovered this [AGE] year old resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On admission, the physician ordered [MEDICATION NAME] 1 mg po (by mouth) TID (three-times-a-day) for restlessness / anxiety. Review of July 2009 monthly physician orders [REDACTED]. - [MEDICATION NAME] 1 mg po every four (4) hours PRN (as needed) and may repeat in two (2) hours if not effective for anxiety, originally ordered on [DATE]; - [MEDICATION NAME] (an antipsychotic) 1 mg at HS (hour of sleep), originally ordered on [DATE] for agitation / restlessness; and - [MEDICATION NAME] 0.5 mg every morning, originally ordered on for dementia with agitation. Review of the Medication Administration Record [REDACTED]. Additionally, the resident received a total daily dose of 4 mg of [MEDICATION NAME] on 06/05/09, 06/06/09, 06/07/09, 06/08/09, 06/11/09, 06/27/09, and 06/28/09. According to OBRA's ""Unnecessary Drugs in the Elderly,"" 2 mg is the maximum dose of [MEDICATION NAME] recommended for use in the elderly. This resident was receiving 3 mg routinely and with the PRN order, had occasionally received 4 mg and 5 mg of [MEDICATION NAME] a day. Further review of the June 2009 MAR found the resident had an order for [REDACTED]. Review of nursing notes, from 04/28/09 to present, revealed the resident had been restless frequently and was attempting to get out of a geri-chair; she spent most of her days in the geri-chair. Observations on 07/28/09, from 8:30 a.m. (at which time the resident was already in a geri-chair in the hallway) to 4:30 p.m., found the resident in a geri-chair in the hallway. Medical record review did not find documentation to reflect assessments of the effectiveness of the current pain medication ([MEDICATION NAME] 5/500 mg) or assessments of the resident's level of comfort while seated in the geri-chair (given her [DIAGNOSES REDACTED]. During an interview on 07/28/09 at 3:00 p.m., the director of nursing (DON - Employee #4) was notified of the total daily amounts of [MEDICATION NAME] the resident was receiving, and no further information was provided. This resident was receiving [MEDICATION NAME] in doses not recommended for use in the elderly and [MEDICATION NAME] (an antipsychotic drug) for restlessness / agitation, but the effectiveness of the pain medication had not been re-evaluated, and the resident's comfort level while seated in the geri-chair had not been assessed as a possible cause of restlessness leading to agitation. b) Resident #20 Medical record review, on 07/28/09, discovered this [AGE] year old resident had been receiving [MEDICATION NAME] 50 mg every day for restlessness since 06/13/07, with no dose reductions attempted in an effort to discontinue this medication According to OBRA's ""Unnecessary Drugs in the Elderly,"" [MEDICATION NAME] is not recommended in the elderly due to its potent [MEDICATION NAME] side effects of dry mouth, blurred vision, [MEDICAL CONDITION], constipation, confusion, possible [MEDICAL CONDITION] or hallucinations. Review of the resident's current care plan, dated 06/11/09 to 09/10/09, revealed the resident had an indwelling Foley catheter for urinary obstruction, risk factors of dehydration, disordered thought processes, and constipation, all of which were possible side effects of [MEDICATION NAME] use Observations of this resident, on 07/28/09 and 07/29/09, found him in his room; he slept most of the day and did not respond verbally. In an interview on 07/29/09 at 12:15 p.m., the DON confirmed a gradual dose reduction of [MEDICATION NAME] had not been attempted as required. c) Resident #11 The medical record of Resident #11, when reviewed on 07/27/09 at 3:00 p.m., disclosed this [AGE] year old male had been admitted to the facility on [DATE] and admitted to the services of Hospice on 06/11/09, with the terminal [DIAGNOSES REDACTED]. Nursing documentation described episodes of restlessness, trying to climb out of bed, etc., on occasion. On 06/26/09, the resident received a physician's orders [REDACTED]. The resident had received this injection on one (1) occasion in July (07/18/09) when, according to nursing notes, the resident was experiencing ""increased anxiety noted, no relief with nursing interventions"". On 07/20/09, the resident's attending physician gave an order for [REDACTED]. The resident received 15 mg of [MEDICATION NAME] for seven (7) days. On 07/27/09, the [MEDICATION NAME] was discontinued when a speech therapist completed a swallowing evaluation and suggested: ""Pt. (patient) has scheduled [MEDICATION NAME] ordered which is possibly the cause of the severe decline in swallow fx (function)."" The resident had the potential to receive 23 mg of [MEDICATION NAME] in a twenty-four (24) hour period. Review of ""Unnecessary Drugs in the Elderly"" (copyright 1992 and revised in 2002) on page 62 states, for antipsychotic medications, the recommended dose of [MEDICATION NAME] for elderly residents with organic mental syndromes is 4 mg per day. .",2015-01-01
10585,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,386,E,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the attending physician for seven (7) of thirteen (13) sampled residents failed to review the resident's total plan of care with each assessment visit by failing to co-sign visits made by a physician's assistant and other consulting physicians, acknowledging lab values, and acknowledging resident visits to the emergency room . Resident identifiers: #56, #1, #24, #20, #49, #15, and #12. Facility census: 60. Findings include: a) Resident #56 The medical record of Resident #56, when reviewed on 07/28/09, disclosed the resident's attending physician had visited on 07/26/09, which was the first visit in several months. At this time, the physician wrote a progress note but failed to acknowledge by co-signing physician's assistant visit to the resident in February or to acknowledge abnormal lab results that had been obtained since his last visit. There was no evidence the physician was aware of these abnormal lab values other than a statement on each ""faxed Dr. (name) NCF I 1/13/09"". There was no signature to signify who had faxed them or that the physician had received the fax. b) Resident #1 The medical record of Resident #1, when reviewed on 07/29/09, disclosed the resident's attending physician had visited on 07/10/09, which was the first visit in several months. At this time, the physician wrote a progress note but failed to acknowledge by co-signing two (2) visits made to the resident by a physician's assistant on 02/24/09 and 02/26/09. c) Resident #24 The medical record of Resident #24, when reviewed on 07/28/09, disclosed the resident's attending physician had visited the resident on 07/26/09, which was the first visit in several months. Although the physician wrote a progress note at this time, he failed to acknowledge by signing or co-signing a hospital discharge report from 05/04/09 and abnormal lab values obtained on 05/05/09 which had been reviewed by another physician. These documents had been obtained and placed on the resident's record since the last physician's visit and total care review. d) Resident #20 Review of physician's progress notes, on 07/28/09, found the resident had been seen on 05/30/09 by a physician's assistant (PA). Review of the PA's note found staff had been advised to administer Klonopin (a sedative drug) about one (1) hour prior to showering the resident. There was no evidence to reflect the attending physician had acknowledged the note and PA's decisions with initials and date of review as required. Review of physician's progress notes revealed the attending physician had been in the facility and entered a progress note into the record on 07/27/09. e) Resident #49 Medical record review, on 07/30/09, disclosed this resident had been admitted to the facility on [DATE]. Review of physician's progress notes found the resident had been seen by a PA on 05/30/09. Further review of the progress notes found the PA's note had not been co-signed by the attending physician, who had been in the facility and entered a progress note into the record on 07/27/09. f) Resident #15 Medical record review, on 07/30/09, disclosed this resident had been seen by a PA on 02/26/09, 04/30/09, 05/30/09, and 06/03/09. Review of the PA's notes revealed the attending physician had not co-signed the notes indicating agreement with assessments and orders written by the PA. g) Resident #12 Medical record review, on 07/28/09, revealed this resident had been seen by a PA on 05/30/09 and 06/26/09. Review of the PA's notes revealed the notes had not been co-signed by the attending physician indicating agreement with assessments. The attending physician had been in the facility and entered a progress note into the record on 07/27/09. h) During an interview on 07/30/09 at 10:30 a.m., the director of nursing (Employee #4) confirmed the physician had not co-signed the PA's progress notes for Residents 20, #49, #15, and #12. .",2015-01-01
10586,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,387,E,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the attending physician for seven (7) of thirteen (13) residents reviewed failed to complete a physician's visit at least once every thirty (30) days for the first ninety (90) days after admission and at least once every sixty (60) days thereafter, as required. Resident identifiers: #24, #56, #1, #41, #12, #49, and #15. Facility census: 60. Findings include: a) Resident #24 When reviewed on 07/27/09, the medical record disclosed this resident had been admitted to the facility on [DATE], following hospitalization for fall resulting in vertebral fracture and a subdural hematoma. Further review disclosed no evidence the resident was seen by her attending physician until 07/26/09. When interviewed on 07/27/09, the facility's director of nursing (DON - Employee #4) could provide no further evidence to reflect the physician had seen the resident at an earlier date. b) Resident #56 When reviewed on 07/28/09, the medical record disclosed this resident had been admitted to the facility on [DATE], having transferred from another facility. Further review disclosed the resident's attending physician had seen her and written a progress note on 01/16/09. A physician's assistant (PA) had visited the patient for a ""chart review"" on 02/26/09. The resident's physician had not made a second visit until 07/26/09. This was confirmed by the DON during an interview at 3:00 p.m. on 07/28/09. c) Resident #1 When reviewed on 07/29/09, the medical record disclosed this resident had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. A progress note, dated 07/10/08, was written by the resident's attending physician. Although the record disclosed numerous physician orders [REDACTED].#1 since that date (07/10/08), until 07/28/09. No evidence to the contrary could be provided by facility staff at the time of exit at 3:00 p.m. on 07/30/09. d) Resident #41 When reviewed on 07/29/09, the medical record disclosed this individual had been a resident of this facility since 2005. When reviewed, it was determined the resident's attending physician had entered a progress note on 04/28/09. A PA had entered a progress note on 05/01/09, and no further visits by a physician or physician extender were documented until 07/26/09. No evidence to the contrary could be provided by facility staff at the time of exit at 3:00 p.m. on 07/30/09. This interval does not meet the requirement that the physician visit the resident every sixty (60) days, which can be alternated with visits by a PA. e) Resident #12 Medical record review, on 07/28/09, discovered this resident had been admitted to the facility on [DATE]. The physician visited and wrote a progress note on 04/28/09. The resident was later seen by a physician's assistant on 05/30/09 and on 06/26/09. There was no evidence to reflect the resident was seen by a physician every thirty (30) days for the first ninety (90) days following admission, as required. f) Resident #49 Medical record review, on 07/30/09, discovered this resident had been admitted to the facility on [DATE]. The entry into the physician's progress notes was made by a PA on 05/30/09. There were no further progress notes until 07/27/09, at which time the resident was seen by the attending physician. There was no evidence to reflect the resident was seen by a physician every thirty (30) days for the first ninety (90) days following admission, as required. g) Resident #15 Medical record review, on 07/30/09, disclosed the attending physician had not alternated visits with the physician's assistant as required. Progress notes revealed the resident had been seen by a PA on 02/26/09, 04/24/09, 05/30/09, and 06/03/09, with no alternating visits by the attending physician. h) During an interview on 07/30/09 at 1:30 p.m., the DON confirmed the attending physician did not make the required visits following admission to the facility or alternate visits with the PA for Residents #12, #49, and #15. .",2015-01-01
10587,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,514,D,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, facility staff failed to maintain medical records, for three (3) of fifteen (15) fifteen residents reviewed, in a well organized, accurate, and complete manner. Medical documents and resident information related to services contracted through a hospice provider were not available on the resident's medical record for two (2) residents, and a document completed on an occupational therapy form incorrectly stated several resident diagnoses. Resident identifiers: #11, #3, and #56. Facility census: 60. Findings include: a) Resident #11 The medical record of Resident #11, when reviewed on 07/27/09 at 3:00 p.m., disclosed this [AGE] year old male had been admitted to the facility on [DATE] and admitted to the services of Hospice on 06/11/09 with the terminal [DIAGNOSES REDACTED]. The resident's medical record contained no information related to Hospice. A Hospice nurse (Employee #84) at the facility at that time explained that each Hospice patient had a separate chart for this information. The Hospice record was reviewed. A document titled ""Interdisciplinary Group Meeting"" (with no date) stated the Hospice chaplain visit frequency was ""1 X month (once a month)"". Further review disclosed no evidence the Hospice Chaplain had visited the resident. The Hospice nurse was again questioned and stated this documentation would be on his record at the Hospice office. The Hospice nurse agreed the information should be on the record at the nursing facility, and she called the Hospice office to have the documents faxed to the facility. b) Resident #3 The medical record of Resident #3, when reviewed on 07/29/09 at 3:00 p.m., disclosed this [AGE] year old male had been admitted to the facility on [DATE] and admitted to the services of Hospice on 06/11/09 with the terminal [DIAGNOSES REDACTED]. The Hospice record was reviewed. A document titled ""Interdisciplinary Group Meeting"" (with no date) stated the Hospice chaplain visit frequency was ""1 X month"". Further review disclosed no evidence the Hospice Chaplain had visited the resident. The Hospice Office was contacted, and this missing documentation was faxed to the facility to be placed on the resident's current medical record. c) Resident #56 The medical record of Resident #56, when reviewed on 07/28/09, disclosed this [AGE] year old resident was admitted to the facility on [DATE]. The list of [DIAGNOSES REDACTED]. A document entitled ""Plan of Treatment for Outpatient Rehabilitation"" and completed 07/02/09, in Item #20 Initial Assessment, described this resident as having [MEDICAL CONDITION] disorder, nonpsychotic mental disorder, and [MEDICAL CONDITION] in addition to the [DIAGNOSES REDACTED]. On 07/28/09 at approximately 11:00 a.m., the facility's director of nursing (DON - Employee #4) was asked to review this record and determine whether these additional [DIAGNOSES REDACTED]. The DON later confirmed these [DIAGNOSES REDACTED].",2015-01-01
10588,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,332,D,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater. One (1) of three (3) nurses (Employee #11) observed administering medications, with forty (40) opportunities for error, incorrectly crushed two (2) medications for Resident #55 that were not formulated to be crushed. Resident identifier: #55. Facility census: 60. Findings include: a) Resident #55 During the medication pass observation on 07/27/09 at 3:30 p.m., the nurse (Employee #11) was observed preparing the following medications for Resident #55: [MEDICATION NAME] 400 mg, EC ([MEDICATION NAME] coated) Aspirin 81 mg, Senna tab, [MEDICATION NAME] 100 mg, and Vitamin C 500 mg. During the preparation, the nurse crushed all of these medications except [MEDICATION NAME] 100 mg. When this surveyor questioned the nurse which medications were crushed, the nurse stated, ""I crushed everything except the [MEDICATION NAME]."" Review of the facility's ""Do not Crush list"" revealed the [MEDICATION NAME] coated aspirin and [MEDICATION NAME] should not have been crushed. During an interview on 07/29/09 at 10:30 a.m., the director of nursing (DON - Employee #4) confirmed [MEDICATION NAME] coated aspirin and [MEDICATION NAME] should not have been crushed. .",2015-01-01
10589,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,371,F,0,1,OPXH11,"Based on observation and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 60. Findings include: a) During the initial tour of the kitchen, on 07/27/09 at 1:15 p.m., observation found coffee cups stacked on top of each other on trays. The cups had been stacked prior to complete air drying and had trapped moisture, creating a medium for bacteria growth. b) During the initial tour of the kitchen on 07/27/09 at 1:15 p.m., and during further kitchen observations on 07/29/09 at 11:00 a.m., flies were observed in the food preparation and serving areas. This practice had the potential to result in food contamination and compromised food safety. c) During an interview on 07/27/09 at 1:30 p.m., the assistant dietary manager (Employee #82) confirmed there was trapped moisture in the coffee cups and flies were a problem in the kitchen due to use of the back door located in the kitchen area. .",2015-01-01
10590,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,469,E,0,1,OPXH11,"Based on observation, resident interview, and staff interview, the facility failed to maintain an effective pest control program so the facility was free of flies in the kitchen and resident living areas. During the course of the survey, flies were observed in the facility kitchen and in resident care areas of the facility on the hospital side. A confidential resident interview revealed flies were a problem in resident rooms and in the facility dining areas. This had the potential to affect all residents who reside in the facility. Facility census: 60. Findings include: a) During the initial tour of the kitchen on 07/27/09 at 1:30 p.m., and during additional kitchen observations on 07/29/09 at 11:00 a.m., flies were noted in the food preparation and serving areas of the kitchen. In an interview on 07/27/09 at 1:30 p.m., the assistant dietary manager confirmed flies were a problem in the kitchen due to a back door used in the kitchen area. b) During the medication pass observation task on 07/27/09 at 3:30 p.m., a fly was observed around the medication cart in the hallway in the hospital side of the facility. c) During a confidential resident interview on 07/28/09 at 4:00 p.m., the resident complained that flies were occasionally a problem in both resident rooms and in the resident dining areas. d) During an interview on 07/30/09 at 2:15 p.m., the administrator was informed of the observation and complaint about flies in the facility. .",2015-01-01
10591,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,315,D,0,1,OPXH11,"Based on record review and staff interview, the facility failed to ensure planned interventions for improving a resident's urinary continence status were implemented for one (1) of thirteen (13) residents reviewed. Resident identifier: #56. Facility census: 60. Findings include: a) Resident #56 A comparison of Resident #56's two (2) most recent minimum data set (MDS) assessments disclosed a decline in the resident's urinary continence status. On the MDS with an assessment reference date (ARD) of 04/19/09, the assessor entered a code of ""1"", indicating she was ""occasionally incontinent"". On the MDS with an ARD of 07/09/09, the assessor entered a code of ""2"", indicating she was now ""frequently incontinent"". Review of the resident's most current care plan, revised on 07/09/09, found the following problem statement: ""Risk for alteration in patterns of Urinary Elimination RT (related to) disordered thought processes and infrequent urinary incontinence."" The goal related to this problem stated: ""Resident will not experience further loss of urinary function by review date."" Interventions to achieve this goal included: ""Implement bladder re-training program with all personnel, resident and family if indicated. Observe voiding pattern determine what stimuli precipitate voiding. Comprehensive evaluation of incontinence pattern to determine potential for management program."" A nurse responsible for this resident on 07/29/09 at 3:00 p.m. (Employee #29), when questioned as to what steps were being taken with this resident related to her urinary incontinence, stated the nursing assistants documented each time the resident voids. When further questioned, this nurse stated the resident was not now and, as to her knowledge, never was on a bowel and bladder retraining program. .",2015-01-01
11105,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2011-04-27,155,D,1,0,MWLC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, record review, and policy review, the facility failed to ensure that a resident's right to refuse treatment. This was evident for one (1) of six (6) sampled residents, who possessed the capacity to understand and make informed health care decisions. The resident refused an injection when he was attempting to leave the facility, and the nurse gave the injection contrary to his wishes. The syringe contained a psychoactive medication ([MEDICATION NAME]). Resident identifier: #23. Facility census: 61. Findings include: a) Resident #23 1. Interview with a social worker (Employee #312), on 04/26/11 at 3:30 p.m., revealed that, on 03/03/11, she observed staff physically trying to pull Resident #23, who was attempting to leave the facility. Employee #312 said she went outside and informed staff they could not do that, as the resident has capacity. She stated that, at one point during this incident, a licensed practical nurse (Employee #35) allegedly told the resident, ""I have the insulin the doctor wants you to take,"" but it was [MEDICATION NAME], instead. At that point, the nurse left him alone and did not administer the injection. Employee #312 said, at another point, she looked out her window and saw two (2) maintenance men and the administrator talking to the resident, and the workers had their hands on the resident. She said those staff members somehow got him back inside the fence, and Employee #35 allegedly gave the injection of [MEDICATION NAME] through his clothing. - 2. Interview with another social worker (Employee #119), on 04/27/11 at 8:30 a.m., revealed Resident #23 was determined by his attending physician on 12/10/10 to have health care decision-making capacity, but at the time of the incident on 03/03/11, Resident #23 was extremely out of control. She said this resident walks with a crutch or a cane, and that was his weapon that day, although he did not hit anyone. Both she and the director of nursing (DON) agreed that Employee #35 gave Resident #23 an injection of [MEDICATION NAME] during the incident. - 3. Review of the facility's policy titled ""Against Medical Advice Discharge"" (revised 09/2008), produced by Employee #119 on 04/27/11 at 12:40 p.m., revealed the following statement: ""No capacitated resident will be held in the nursing facility against their wishes, unless with a court order. Any incapacitated resident cannot be responsible for their medical decisions. These residents will not be allowed to leave the facility as they wish."" - 4. Interview with Employee #35, on 04/27/11 at 4:30 p.m., revealed when she came to work at 3:00 p.m. on 03/03/11, Resident #23 was already upset and agitated because his wife had come to the facility and brought him some clothing, but he thought he was going home. The family, however, did not want to take him home. Employee #35 asked Resident #23 if she could give him something to calm his nerves, but he refused, so she backed away with the [MEDICATION NAME]. The resident was on the grounds but outside the fence and was in and out of the facility numerous times during this hour-long episode, and police were on the scene at one point. She called the physician, who allegedly told her he had capacity, so let him leave if he wants to, but she spoke her fear that the resident could enter the highway and get killed, and she would be held liable for manslaughter. She said the physician, then, gave her the order to give the resident [MEDICATION NAME] 0.5 mg. According to Employee #35, while staff distracted the resident and tried to take his cane, she gave the injection of [MEDICATION NAME]. Resident #23 was not held down and was not restrained while the injection was given. - 5. Review of the medical record revealed that, on 03/14/11, the facility's medical director (Employee #81) evaluated the resident and determined that he lacked capacity related to dementia with cognitive loss, disorientation to person / place / time, and the inability to understand or make medical decisions, with expected long-term incapacity. - 6. Review of the attending physician's progress notes, dated 03/18/11, found the attending physician ""did not have him declared as lacking mental capacity and with some coercion he got [MEDICATION NAME] intramuscularly and apparently he settled down. I have seen him in the clinic since then to see if I need to change his mental status evaluation ... and I did not change it."" - 7. During an interview with Resident #23 on 04/27/11 at 4:45 p.m., he said he recalled being mad once when they (facility staff) would not let him leave when he wanted to go home. He did not have clear recall about any injections other than insulin, and he said he had never been hurt by anyone at the facility. .",2014-08-01
11106,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2011-04-27,225,D,1,0,MWLC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview and record review, the facility failed to immediately report, in accordance with State law, an alleged violation involving resident abuse / mistreatment involving one (1) of six (6) sampled residents who possessed capacity and who received an injection of a benzodiazapine drug ([MEDICATION NAME]) without his consent. Resident identifier: #23. Facility census: 61. Findings include: a) Resident #23 Record review revealed Resident #23 was offered an injection which he refused on 03/03/11, but the nurse soon afterward gave the injection without first telling the resident what she was going to do and obtaining his consent. During an interview with the nurse (Employee #35) on 04/27/11 at 4:30 p.m., she said she called and obtained a physician's orders [REDACTED].#23 an injection of [MEDICATION NAME] when he was trying to leave the facility, because she feared he might go out to the road and get killed. She said facility staff distracted the resident and she gave the injection intramuscularly at approximately 4:00 p.m. on 03/03/11. Record review found the facility completed an incident report on 03/04/11; an Adult Protective Service Report on 03/14/11; a complaint report to the West Virginia State Board of Examiners for Licensed Practical Nurses on 03/17/11; and there was a fax cover sheet to the State survey and certification agency (Office of Health Facility Licensure and Certification - OHFLAC) dated 03/14/11. Review of Abuse / Neglect Reporting Requirements for West Virginia Nursing Homes and Nursing Facilities found that alleged violations of mistreatment, neglect, or abuse under subset 483.13 (c)(2) must initially be reported within twenty-four (24) hours to OHFLAC and to other officials in accordance with State law, and under subset 483.13 (c)(4), the results of the facility's investigation must be reported to OHFLAC and to other officials in accordance with State law within five (5) working days of the incident. During an interview with a social worker (Employee #119) and the director of nursing (DON) on 04/27/11 at 1:25 p.m., neither could find evidence of the immediate or five (5) day reporting to OHFLAC, but they produced a fax cover sheet to OHFLAC dated 03/14/11, the same date the APS report was completed. Also, review of the front of the incident report dated 03/03/11 had a ""checkmark"" noting they intended to send the incident report to OHFLAC. .",2014-08-01
11107,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2011-04-27,250,D,1,0,MWLC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to identify medically-related social service needs of the resident, and assure the needs were met by the appropriate disciplines. This was evident for one (1) of six (6) sampled residents who was determined by a physician to lack capacity, but who had no legally-appointed surrogate decision-maker in place. Resident identifier: #23. Facility census: 61. Findings include: a) Resident #23 Record review revealed Resident #23 was determined by his attending physician to possess the capacity to understand and make informed health care decisions, as evidenced by documentation on a physician determination of capacity form dated 12/10/10. Further review revealed Resident #23 was subsequently determined by the facility's medical director to lack this capacity, with the incapacity expected to be of long-term duration related to a [DIAGNOSES REDACTED]. Review of a social service progress note, dated 03/14/11 at 8:30 a.m., by a social worker (Employee #312) found the medical director evaluated Resident #23 for capacity on this date, and the resident grabbed his cane and became agitated and combative with the physician. The social worker and the medical director reviewed paperwork from a previous stay at an inpatient psychiatric facility and confirmed the [DIAGNOSES REDACTED]. -- Review of the attending physician's progress note, dated 03/18/11, revealed the facility's medical director saw Resident #23 and declared him to lack the ability to make health care decisions. However the attending physician ""heard secondhand ... that the patient could not understand (the medical director) too well and got frustrated and somewhat angry and the overall interview did not go too well. This will have to be addressed sometime in (sic) future again I am sure."" He went on to write, ""I think he really does not lack the ability to make certain decisions."" -- Review of a social service progress note, dated 03/25/11 at 11:00 a.m. by Employee #312, revealed the social worker had a conversation with the director of nursing (DON) about Resident #23's capacity. The social worker wrote of plans to call the inpatient psychiatric facility to reschedule his appointment from May 2011 to an earlier date to have them do an ""evaluation and determine capacity as well. However, (name of the facility) stated they don't do that on (sic) out patient basis."" Record review found the cause of the resident's previous incapacity, on 07/02/10 while a patient at an acute care hospital, was due to ""IPH"" (right temporal lobe intraparenchymal hematoma) and ""SDH"" (subdural hematoma). The checklist for surrogate selection was completed at that time, and the daughter was found to be the best qualified to act as a surrogate, noting the wife was ""not appropriate to make decisions at this point"". The resident returned home to live until he was admitted to the nursing facility in December 2010, following a month long inpatient psychiatric stay. -- In an interview on 04/26/11 at 3:30 p.m., Employee #312 she spoke her opinion that, if a person is deemed incapacitated, it needs only one physician to regain capacity status; but to declare non-capacity of a previously capacitated person, it requires two (2) physician statements. Employee #312 further stated, that in July 2010, Resident #23 was determined to be incapacitated / lacking decision making capacity while hospitalized at Ruby Memorial Hospital, and the resident's daughter was appointed the surrogate decision-maker, adding that the spouse was not capable of serving in the role. She further stated that she had spoken with Resident #23's daughter, and the daughter allegedly said she thought hospital form appointing her the surrogate decision-maker was null and void when the resident left the hospital and returned to his home, and the daughter withdrew as the person and deferred to the mother to be the decision-maker. The daughter allegedly said her mother was ""making her life a living hell"" when the daughter tried to make any decisions for the resident. Review of social service progress notes, dated 03/11/11 at 12:15 p.m., attested to the social worker's conversation with the daughter, who said she ""withdrew as person"" because her mother was very angry about the daughter having been selected to make decisions. The daughter allegedly ""expressed concern about her mom and her inability to make good, sound decisions"" and the daughter ""could make them but her mom would 'make life difficult for her'."" When asked if the facility had a policy about capacity or advanced directives, Employee #312 said she did not know of any policy here. -- During an interview with another social worker (Employee #119) on 04/27/11 at 8:30 a.m., she said if a person has capacity, it takes two (2) to say he/she doesn't have capacity, either two (2) physicians, or a physician and a psychiatrist. She said she didn't know how many medical opinions it takes to say a person deemed incapacitated could be deemed to have capacity again. Both she and the DON, when asked, said they weren't sure which of the two (2) differing physician opinions to go with regarding capacity, and they didn't know what they would do if he wanted to home today. When interviewed again on 04/27/11 at 3:30 p.m., Employee #119 said Resident #23 has no medical power of attorney (MPOA) or health care surrogate (HCS) at this point in time. She agreed the medical director assessed him as lacking capacity on 03/14/11, which was the most recent physician determination of capacity form in the resident's record, and said the former social worker (Employee #312), had talked about having the Department of Health and Human Resources (DHHR) be his surrogate, adding there had been some discussions with the wife over the phone but agreeing no decision had been reached yet. Employee #119 also stated she had spoken with the wife over the telephone several times and felt the wife could not comprehend what she was being told. -- During an interview with a licensed practical nurse (LPN - Employee #35) on 04/27/11 at 4:30 p.m., she said the resident's wife was the one who would be notified of any changes, falls, or incidents that occurred with Resident #23, but in her opinion, the wife wasn't any better capacitated than the resident. During an interview with the nurse manager (Employee #165) on 04/27/11 at 4:40 p.m., she said she assumed it would be the wife who would be notified of any changes with the resident if he should fall or have any medical or condition changes. She looked at the resident's chart and said, ""It's usually on the condition alert page who to notify, but there isn't anything there."" During an interview with the DON on 04/27/11 at 4:42 p.m., she said the person to notify was usually put on the condition alert for fast check, but it wasn't there. -- Review of the Health Care Decisions Act related to interinstitutional transfers found at 16-30-13: ""In the event that a person admitted to any health care facility in this state has been determined to lack capacity and that person's medical power of attorney has been declared to be in effect or a surrogate decision maker has been selected for that person all in accordance with the requirements of this article and that person is subsequently transferred from one health care facility to another, the receiving health care facility may rely upon the prior determination of incapacity and the activation of the medical power of attorney or selections of a surrogate decisionmaker as valid and continuing until such time as an attending physician, a qualified physician, a qualified psychologist or advanced nurse practitioner in the receiving facility assesses the person's capacity. Should the reassessment by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner at the receiving facility result in a determination of continued incapacity, the receiving facility may rely upon the medical power of attorney representative or surrogate decisionmaker who provided health care decisions at the transferring facility to continue to make all health care decisions at the receiving facility until such time as the person regains capacity."" .",2014-08-01
11108,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2011-04-27,274,D,1,0,MWLC11,". Based on medical record review, staff interview, and policy review, the facility failed to follow its own policy with implementing a significant change in condition minimum data set (MDS) assessment for one (1) of six (6) sampled residents, when a resident's capacity status had been changed from capacity to incapacity status and was not expected to return. Resident identifier: #23. Facility census: 61. Findings include: a) Resident #23 Record review revealed the facility's medical director changed Resident #23's capacity status from capacitated to non-capacitated on 03/14/11, citing this incapacity as expected to be of long term duration and related to his dementia. The nature of the incapacitation was evidenced by cognitive loss, disorientation to person, place and time, and the inability to understand or make medical decisions. Review of the most recent MDS for Resident #23, dated 03/10/11, revealed this was an abbreviated quarterly review assessment. During an interview with the director of nursing (DON) on 04/27/11 at 11:45 a.m., she said they did not complete a significant change MDS when this resident's condition changed from capacity to incapacity. She said the quarterly care plan was due at that time, so they completed a quarterly assessment on Resident #23. Review of the facility's policy related to changes in capacity / incapacity (revised September 2008) revealed, under section D,: ""MDS Coordinator will be notified by nursing immediately by phone. Nursing will prepare information to present at the next weekly Resident Review Meeting. The team will then implement a Significant Change in Condition MDS if incapacity is not expected to change."" .",2014-08-01
11109,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2011-04-27,280,D,1,0,MWLC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to revise the care plan for one (1) of six (6) sampled residents when the resident exhibited a change in capacity status and a significant change in emotional status with identifiable triggers, which were not included on the plan of care. Resident identifier: #23. Facility census: 61. Findings include: a) Resident #23 Record review revealed Resident #23 was determined by his attending physician to possess the capacity to understand and make informed health care decisions, as evidenced by documentation on a physician determination of capacity form dated 12/10/10. Further review revealed Resident #23 was subsequently determined by the facility's medical director to lack this capacity, with the incapacity expected to be of long-term duration related to a [DIAGNOSES REDACTED]. Review of the current care plan, with initiation date of 03/10/11, found no mention of his status having changed to incapacity, nor of who was to serve as his surrogate decision-making (and was to be notified in the event of physical, mental, or emotional condition changes, or medication or treatment changes). Review of Resident #23's medical record revealed ongoing domestic issues within the family, and the spouse was known by the facility to trigger an escalation in the resident's agitation. However, review of the current care plan found it did not address the spouse as a trigger for his behaviors and agitation, nor were any plans developed to circumvent future instances of this nature. Review a psychiatric admission history and physical (H&P) dated 11/01/10 revealed this resident was admitted to an acute care hospital on [DATE] and discharged on [DATE], with the resident exhibiting mild dementia at his baseline prior to the discovery of a subdural hematoma. The resident had, reportedly, been hit in the head by a family member ten (10) days prior to sustaining a fall and hematoma. While in a step-down unit, the ""patient was noted to be agitated with problems of impulsivity that required restraints multiple times."" Further review of the H&P dated 11/01/10 revealed this resident initially transferred into the psychiatric unit after being admitted through the emergency department due to domestic violence (.i.e., ""he was hitting his wife and his son had to protect his mother""). The resident stayed at the acute care hospital for five (5) days before being transferred to an inpatient psychiatric facility due to continuing agitation, aggression, and confusion. Record review of neuropsychological testing completed 12/01/10 found: ""Records indicate that he has significant functional decline, and his relationship with his wife is extremely impaired."" Furthermore, ""Keeping an eye on him for safety will be increasingly important given the severity of his memory problems. He will require extensive supervision during most activities. Records indicate that he is also presenting with significant behavioral and emotional problem which will require ongoing management."" Review of social service progress notes, dated 03/03/11 beginning at 3:00 p.m., revealed the wife visited the resident, then entered the social worker's office and stated, ""You can't let him leave out that door."" Early during this incident of resident agitation and attempting to leave the facility, Employee #312 tried to separate the wife and the resident and encouraged the wife to leave at that time due to the resident being angry, but she refused. Finally, she did leave. This episode of increased agitation lasted approximately an hour and involved police intervention. Review of nursing notes, dated 03/04/11, 03/08/11, and 03/09/11, revealed the resident's wife called and spoke with nurses of her concern that the resident might come home, once stating, ""You just don't understand what I went through."" Review of a physician's progress note dated 03/18/11 found he ""got the overall idea that his wife, if anything, was agitating him more than she was trying to help"", related to the incident which occurred 03/03/11 when the wife visited. During an interview with a social worker (Employee #312) on 04/26/11 at 3:30 p.m., she stated Resident #23 had confusion at times but can always be redirected, and he had never been aggressive before the incident on 03/03/11. Interview with another social worker (Employee #119), on 04/27/11 at 8:30 a.m., revealed Resident #23 previously lived at home but allegedly attacked his wife, who called the police and an ambulance. He was taken to the emergency department and, from there, to an inpatient psychiatric hospital in November 2010. She said the wife had not been to the facility before or after the 03/03/11 incident, at which time she visited and the resident became extremely agitated. However, the wife sometimes calls and to speaks with him, and after he talks with her, he acts ""kind of agitated"". She added that the wife ""doesn't seem to comprehend what you're saying"". During an interview with the director of nursing (DON) on 04/27/11 at 11:45 a.m., she said they did not care plan specific interventions about behavioral triggers (such as the wife) and said, possibly, they should have done more specific care planning in that area, as the wife allegedly will also cause him to become agitated with telephone calls. The DON agreed they did not have a written plan in place for if or when the wife would show up again at the facility. During an interview with a licensed practical nurse (Employee #35) on 04/27/11 at 4:30 p.m., she said the wife allegedly had a court order against the resident. She stated there was currently no plan in place if the wife should return to the facility; rather, they will just have to react to whatever circumstances happen.",2014-08-01
1286,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-01-10,641,D,0,1,Z38R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed and coded for two (Residents #71 and #163) of 26 sampled residents whose MDS assessments were reviewed. The facility's census was 180 residents. Findings include: a) Resident #71 On 01/08/19 at 12:55 PM, the clinical record of Resident #71 was reviewed. Resident #71 had [DIAGNOSES REDACTED]. physician's orders [REDACTED].#71's feeding tube was to be checked for placement before water flushes each shift. The quarterly Minimum Data Set (MDS) assessment, dated 11/13/18, documented Resident #71 had moderate impairment in cognitive skills for daily decision making. Section J documented a pain assessment interview should be conducted. However, Resident #71's pain status including pain presence, pain frequency, pain effect on function and pain intensity was not been assessed through an interview. Additionally, section K 0510 documented the resident did not have a feeding tube. The comprehensive care plan, most recently reviewed/revised on 11/20/18, documented the Resident #71 had problems pertaining to his potential for pain and his risk for complications related to his feeding tube . On 01/08/19 at 3:52 PM, the findings regarding the MDS assessment dated [DATE] were reviewed with MDS Coordinator #86. She reviewed the assessment and stated Resident' #71's pain status had not been assessed and should have been. She further stated the resident did have a feeding tube and the assessment was not accurate regarding the coding of no feeding tube. 2. Resident #163 On 01/08/19 at 10:15 AM, the clinical record of Resident #163 was reviewed. It documented the resident had [DIAGNOSES REDACTED]. The admission, comprehensive MDS assessment, dated 09/18/18, documented Section B0100 that Resident #163 was not in a persistent vegetative state/no discernible consciousness. The assessment had no documentation that Section C-cognitive patterns, Section D-Mood and Section E-Behavior had been assessed. The comprehensive care plan, most recently reviewed/revised 12/27/18, documented Resident #163 had problems pertaining to cognitive loss as evidenced by short term and long term memory problem, impaired decision making and dementia diagnoses. The care plan documented the resident had a communication problem related to impaired cognition. On 01/08/19 at 12:21 PM, MDS Coordinator #86 was asked to review the MDS assessment, dated 09/18/18, for documentation of the resident's cognitive status, mood status and behavioral status. She acknowledged Resident #163's 's cognitive, mood and behavioral status had not been assessed. She stated Social Worker #57 was responsible to complete those sections of the MDS. On 01/08/19 at 12:29 PM, Social Worker #57 was asked to review the incomplete assessment. She reviewed the MDS and stated the assessment was not complete and accurate because Resident #163's cognitive, mood and behavioral status had not been assessed.",2020-09-01
1287,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-01-10,656,D,0,1,Z38R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to implement a comprehensive person-centered care plan to prevent falls. Specifically, the facility failed to follow the care plan for non-skid socks for one (Resident #41) of 26 sampled residents. The facility census was 180. Findings included: a) Resident #41 Review of the face sheet on 01/14/19 at 7:00 AM for Resident #41 revealed [DIAGNOSES REDACTED]. The resident was admitted on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/01/18, revealed the resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score 1 of 15. Review of the care plan on 01/14/19 at 7:00 AM, revised 11/04/18, revealed potential for injuries from falls, history of frequent falls and fall with fracture, muscle weakness, unsteady gait, dementia, decreased functional mobility, episodes of incontinence, [MEDICAL CONDITION] drug use. Interventions included: resident to wear non-skid socks when out of bed (created 12/25/18). Resident #41 was observed in her room on 01/08/19 at 1:37 PM. She was standing at the sink washing her hands with Licensed Practical Nurse (LPN) #23 by her side. The LPN helped her to a chair next to the sink and then to the bed. She was observed having difficulty with walking. The resident was observed with pink fluffy socks on her feet. When asked if the resident was wearing non-skid socks, the LPN said, Yes. She had a pair like that at home. The LPN went over to Resident #41 and lifted her feet. The socks did not have the skid free strips. The LPN confirmed the socks were not skid free. She then replaced with the appropriate socks. Certified Nurse Aide (CNA) #84 was interviewed on 01/08/19 at 2:07 PM. She stated that she was the one who dressed Resident #41 this morning. When asked if the resident was a fall risk, she said Yes. The resident used to be independent. The CNA confirmed she put the pink fluffy socks on the resident. The resident liked those socks because her feet got cold. When asked if the socks were skid free, she stated the resident must have gotten those socks during the holiday. They usually had the correct socks available. The Assistant Director of Nurses (ADON) was interviewed on 01/10/19 at 9:08 AM. She stated Resident #41 might have gotten the wrong socks from the holiday. The families were not always aware of the resident's need for the skid-free socks. They would have to check her room to make sure the resident did not have the regular socks available. Review of the Fall Management policy on 01/14/19 at 7:26 AM, revised 10/2018, revealed if the resident is high risk for falls, the nurse/interdisciplinary team will evaluate interventions and implement these interventions to minimize fall occurrences.",2020-09-01
1288,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-01-10,675,D,0,1,Z38R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to ensure proper positioning in the dining room for one (Resident #95) of one sampled resident reviewed for positioning. The facility census was 180. Findings included: a) Resident #95 Review of the face sheet on 01/14/19 at 7:15 AM for Resident #95 revealed [DIAGNOSES REDACTED]. The resident was admitted on [DATE] with readmission 08/22/18. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/29/18, revealed the resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score 2 of 15. Resident #95 was observed in the dining room on 01/08/19 at 8:26 AM. She was feeding herself breakfast. Her table was at chin height for the resident. Resident #95 had to lift her head and reach over the top of the table for her food. She was observed having difficulty with the milk carton. The staff placed the milk into a plastic cup. Resident #95 had to lift the beverages off the table and bring to her mouth, at a lower position. Resident #95 was observed on 01/08/19 at 11:38 AM. She was at a table putting the clothing protector on herself. When asked about the table height, Resident #95 stated, Can't expect them to lower the table for me. She said, she manages. -At 12:46 PM, the table was observed at chin height for the resident. Resident #95 had to lift her arm over the table to reach her food. -At 1:08 PM, Resident #95 was observed to eat very little of her meal. Unit Manager #102 was interviewed on 01/09/19 at 8:48 AM. When asked about the table height for the residents, she said that maybe Occupational Therapy (OT) or Speech Therapy (ST) would look at that. She thought the table height was appropriate. Rehab Manager (RM) #289 was interviewed on 01/09/19 at 9:13 AM. She stated that OT would evaluate the table heights for the residents. Typically, they would see the residents if they had a screen in self feeding. The tables in the dining room were able to be lowered and raised. Their recommendation would have been to place the resident at a lower table. The therapy staff did not regularly go into the dining room. When asked if chin height was an appropriate height for a resident, she said No. Resident #95 was observed on 01/09/19 at 8:03 AM. The table remained at chin height for the resident. Resident #95 had to lift her head and lift her arm over the table to reach her food. RM #289 was interviewed again on 01/09/19 at 3:54 PM. She had sent OT into the dining room to assess table heights. She stated they made a list of residents that needed to be evaluated. The table needed to be at elbow height. They had identified around 7-10 residents that needed to be seen. Review of the Serving a Meal policy on 01/14/19 at 7:05 AM, dated 11/27/17, revealed prepare the room or serving area for mealtime (decrease noise level, provide lighting, position comfortably) .",2020-09-01
1289,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-01-10,690,D,0,1,Z38R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews, the facility failed to assess for the removal of an indwelling catheter for one (Resident #106) of two sampled residents reviewed for catheters. Specifically, the facility did not assess for the removal of the indwelling catheter after pressure ulcers had been healed. The facility census was 180. Findings included: a) Resident #106 According to the Face sheet, reviewed on 01/08/19, Resident #106 was readmitted to the facility on [DATE]. Resident #106 had [DIAGNOSES REDACTED]. According to the 5-day Prospective Payment System (PPS) Minimum Data Set (MDS) assessment, dated 11/30/18, Resident #106 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 14 out of 15. She required extensive to total assistance with all activities of daily living (ADL). She had an indwelling catheter. Resident #106 was interviewed on 01/08/19 at 8:10 AM. She said her catheter was placed when she was in the hospital a few weeks ago. She had sores behind her thighs and the hospital thought they would heal quicker if she had a catheter. Resident #106's care plans were reviewed on 01/08/19 at 8:21 AM. A care plan revised 11/30/18 identified the resident as having an indwelling catheter and there was potential for infection or dysfunction. Interventions included providing care every shift and as needed, emptying the catheter bag every shift and as needed, ensuring the catheter bag is positioned beneath the level of the bladder and observing for pain or discomfort. There was no rational for why the resident had a catheter. The 01/2019 physician's orders [REDACTED]. The orders included an order for [REDACTED]. There was no rationale for the use of the Foley in the orders. A physician's progress note, dated 11/28/18, documented the resident had an indwelling Foley catheter at the time for multiple pressure areas. The pressure areas included: open area to left posterior thigh, stage two pressure ulcer to right inner thigh, stage two pressure ulcer to left inner thigh, deep tissue injury (DTI) to left posterior thigh, and stage two pressure ulcer to right buttock. The plan included continuing the Foley catheter for management. A progress note dated 12/05/18 regarding an internal meeting documented the resident had a recent hospitalization and returned with multiple skin issues. The resident currently had a Foley catheter. A progress note dated 12/07/18 documented several skin impairments had resolved including the stage two pressure ulcer to the right buttock. Further treatment for [REDACTED]. A progress note dated 12/13/18 documented the resident's wounds were improving. The stage two wound to the right inner thigh had resolved. A progress note dated 12/20/18 documented the stage two pressure ulcer to the right inner thigh and left inner thigh along with DTI to posterior thigh had resolved. Treatment recommendations were discontinued. A Foley catheter was in place. Following the wounds resolving on 12/20/18, there were no nursing notes or physician notes regarding the ongoing need for the Foley catheter. According to the progress notes and physician's orders [REDACTED].#106 was started on antibiotics on 01/01/19 for Extended Spectrum Beta-Lactamase (ESBL) in her urine. Licensed Practical Nurse (LPN) #247 was interviewed on 01/08/19 at 3:58 PM. She said Resident #106 had a catheter because of her wounds and for ESBL in her urine. She said the hospital put in the catheter the last time she was in the hospital in November. She said they had thought about removing the catheter but they wanted to wait until her wounds had healed. She thought Resident #106 still had her wounds. They were healing, but had not healed yet. Registered Nurse (RN) #223 was interviewed on 01/08/19 at 4:02 PM. She was the treatment/wound nurse. She confirmed Resident #106 did not have wounds any longer. She said the wounds healed approximately two weeks ago. She was no longer seeing the resident. She said they wanted to keep the catheter in for prevention of future wounds. She said the resident and her daughter request for the resident to have the catheter. Certified Nurse Aide (CNA) #120 was interviewed on 01/09/19 at 11:49 AM. She said that prior to Resident #106 having a catheter, the resident was always incontinent. The CNAs had to provide incontinence care at least every two hours and sometimes it was more frequently. Resident #106 was interviewed on 01/09/19 at 2:05 PM. She again stated that she got the catheter in the hospital and it was to help heal her wounds. She said she would like to have it removed. The only reason she wanted it, was if it was going to heal her wounds. She was under the impression that she still had her wounds. She said she would ultimately prefer to have the catheter removed. She said she was incontinent without the catheter. Unit Manager #222 was interviewed on 01/09/19 at 3:00 PM. When asked why the resident had a catheter, she shrugged. She said that Resident #106 used to have wounds on her thighs and bottom. She thought the wound nurses put the catheter in. At 3:03 PM, the Assistant Director of Nursing (ADON) joined the interview. She said Resident #106 had multiple wounds when she returned from the hospital in November. The wounds resolved on 12/20/18. After the wounds resolved, they failed to remove the catheter. She called the daughter yesterday afternoon to discuss removing the catheter. The daughter did not want to remove the catheter. She was adamant the resident keep the catheter. She wanted the resident to see a urologist prior to removing the catheter. Resident #106 had the catheter for wound management. She is noncompliant with turning and repositioning. She has had several skin issues. Resident #106 did not have a clinical reason to keep the catheter in. She thought it was missed by the wound nurse. Once the wounds were healed, they should have evaluated for removal of the catheter. Unit Manager #222 said it was difficult with the daughter being adamant that the resident have a catheter. The progress notes for 01/08/19 and 01/09/19 were reviewed following the interview with Unit Manager #222 and the ADON. A progress note was made by the ADON on 01/08/19 at 5:17 PM. The progress note documented, Spoke with daughter regarding removing catheter. She has expressed her concerns again as she has in the past of wanting her mom to keep the catheter due to her non-compliant behavior with turning and re-positioning and past skin impairment issues. Daughter requested a urology visit before removing Foley. RN #223 was interviewed for a second time on 01/10/19 at 11:08 AM. She was the treatment/wound nurse. She said Resident #106 was readmitted with the catheter from the hospital. She was not the one that inserted the catheter. The resident's daughter was upset with the hospital because she got wounds, so they kept the catheter in to help heal the wounds. The wounds healed and she missed informing other staff about the possible removal. She normally inquires about the removal of the catheter once wounds are healed. The Director of Nursing (DON) was interviewed on 01/10/19 at 11:32 AM. She confirmed that the hospital inserted Resident #106's catheter. She felt it was appropriate at the time for the resident to have the catheter because she had wounds. Besides the wounds, there was no other indication for use. Once the wounds healed, they should have evaluated for removal of the catheter. The Appropriate Use of Indwelling Catheters policy, dated 11/27/17, was provided by the ADON on 01/09/19 at 7:45 AM. The policy documented in pertinent part, An indwelling urinary catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary . Policy Explanation and Compliance Guidelines: 1. Residents who are admitted with an indwelling urinary catheter, or residents who subsequently receive an indwelling catheter, will be assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary .5. Examples of clinical conditions demonstrating that catheterization is necessary include: a. [MEDICAL CONDITION] that causes persistent overflow incontinence, systematic infections, and/or renal dysfunction that cannot be corrected surgically or managed practically with intermittent catheter use. B. Full thickness or multiple partial thickness wounds that are being contaminated by urine, which has impeded healing despite appropriate care for the incontinence. C. Terminal illness or severe impairment, which makes bed and clothing changes uncomfortable or disruptive .7. Indwelling urinary catheters will be used on a short-term basis, unless the resident's clinical condition warrants otherwise. The interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the insertion, continuation, or removal of an indwelling urinary catheter .",2020-09-01
1290,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-01-10,758,D,0,1,Z38R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure behavior and side effect monitoring for the use of an antianxiety medication had been completed for one ( Resident #71) of five sampled residents whose clinical records were reviewed for unnecessary medications. The facility census was 180. Findings included: a) Resident #71 On 01/08/19 at 12:55 PM, the clinical record of Resident #71 was reviewed and stated the resident had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 11/13/18, documented Resident #71 had moderate impairment in cognitive skills for daily decision making, a staff mood score of 00 and had exhibited no behaviors during the seven days prior to the assessment dated . The assessment documented Resident #71 had received antianxiety and antidepressant medications on seven of seven days prior to the assessment date. A physician's orders [REDACTED].#71 was to be administered [MEDICATION NAME] 75 milligrams three times daily for anxiety. The care plan, most recently reviewed/revised 11/20/18, documented Resident #71 had a problem pertaining to his use of antianxiety medication related to behaviors of verbal complaints of nervousness due to his [DIAGNOSES REDACTED].#71 had potential for increased behaviors and/or side effects from medications. The antianxiety medication care plan documented target behaviors included crying and verbal complaints of nervousness. It documented side effects and antianxiety medication included dizziness, [MEDICAL CONDITION], nervousness, drowsiness, nausea and, if side effects were noted, the physician was to be contacted. The care plan documented staff were to monitor the resident for signs and symptoms of anxiety such as restlessness, wringing hands, tearfulness, rapid heartbeat, rapid shallow breathing, flushed face, dizziness, etc. It documented target behaviors were to be monitored and recorded. The medication administration records (MARs), dated 11/2018, 12/2018 and 01/2019 were reviewed. Beginning on 11/17/18, there was no documentation which indicated the Resident #71 was monitored for target behaviors for the use of [MEDICATION NAME] and/or for side effects of the use of [MEDICATION NAME]. On 01/08/19 at 3:38 PM, the findings were reviewed with Assistant Director of Nursing #115. She reviewed the MARs and stated there was no side effect monitoring and/or no behavior monitoring for the use of [MEDICATION NAME].",2020-09-01
1291,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-01-10,804,E,0,1,Z38R11,"Based on observation, record review and interviews, the facility failed to ensure each resident receives food and drink that is palatable, and at a safe and appetizing temperature. Specifically, the facility failed to ensure residents received food that was proper temperature, the menu had variety and the food was palatable for nine randomly interviewed residents (Residents #167, #63, #165, #58, #14, #139, #111, #27, #7). The facility census was 180. Findings included: a) Residents #167, #63, #165, #58, #14, #139, #111, #27, #7 Resident #167 was interviewed on 01/07/19 at 8:21 AM. He said the only thing he could eat was the peanut butter and jelly. He said the food was bad for the smell, taste and texture. His wife brought in meals several times a week. Resident #63 was interviewed on 01/07/19 08:27 AM. When asked about the food she said, they try but it still tasted bad. Resident #165 was interviewed on 01/07/19 09:05 AM. When asked about the food, he said it's slop. I eat the eggs, but the sausage is horrible and not fit to eat. Resident #58 was interviewed on 01/07/19 at 10:21 AM. She said the food su***. The temperature was cold . the warmer it was the better it tasted. There were a lot of the same foods such as green beans, turkey, chicken and peas. Resident #14 was interviewed on 01/09/19 at 10:52 AM. She said the food was not too good. She was not able to eat heavy food. Resident #139 was interviewed on 01/09/19 at 11:01 AM. When asked about the food, she said Yuck. Most of the time the food was cold. It was not seasoned well. The foods were the same old, same old. She received imitation turkey a lot. The potatoes were cold and not seasoned. She ate in her room. Resident #111 was interviewed on 01/09/19 at 11:12 AM. She stated she did not like the food. It did not taste very good. The food was cold. Nobody from dietary had talked to her about the food. She ate in her room. Resident #58 was interviewed again on 01/09/19 11:16 AM. She said she did not like the food. It was not cooked well. Some of the vegetables were hard and not warm enough. Resident #27 was interviewed on 01/09/19 at 1:21 PM. He said the food was fair. He did not know what food he got when he ordered the cheesesteak. He said there was no cheese on it. Resident #7 was interviewed on 01/09/19 at 2:37 PM. She said they received the same foods every meal such as mashed potatoes, green beans/carrots/peas. She was unable to cut the meat from the night before. She just gave up on it. She did not know what kind of meat it was. She said she hardly ever got hot food. She ate in her room. The following kitchen observations were made on 01/09/19 at 12:22 PM: -At 12:22 PM, a test tray was placed on the cart for B-Hall. The cart was ready for transport at 12:32 PM. The cart arrived on B-Hall at 12:33 PM. The last tray was delivered at 1:03 PM. -The Assistant Food Service Director (AFSD) #66 took the temperatures of the test tray with the following results: -2% milk: 47.9 degrees Fahrenheit (F) -Pork cutlet: 128 degrees F -Mixed vegetables (carrots, broccoli, cauliflower): 127 degrees F. The vegetables had a mushy, overcooked texture. -Sweet potatoes: 124 degrees F Review of the Fall/Winter menus on 01/13/19 at 12:19 PM, revealed the following: Week one: Turkey/chicken were served seven times; green beans were served five times. Week two: Turkey/chicken were served 10 times; green beans were served three times. Week three: Turkey/chicken were served nine times; green beans were served three times. Week four: Turkey/chicken were served nine times. Certified Dietary Manager (CDM) #93 was interviewed on 01/10/19 at 9:45 AM. She stated they only received resident input from the resident council meetings. They had to change some of the menu items based on resident request. She stated she would need to talk to the residents in a broader manner for obtaining food complaints. A lot of the residents ate in their rooms. When asked about the temperatures, she stated she created a test tray to see if she would get the same results. She said the test tray sat for about 45 minutes and received the same temperatures. She stated it was not proper temperature. It failed. The time it took for the food to be served to the residents was too long. Review of the Standardized Menus Policy, dated 11/27/17, revealed menus will reflect, based on a center's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups.",2020-09-01
1292,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-01-10,812,E,0,1,Z38R11,"Based on observation and interviews the facility failed to store, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure cold food was of proper temperature throughout meal service and ensure food preparation equipment was properly cleaned in one of one kitchen. The facility census was 180. Findings include: a) Temperatures The kitchen was observed on 01/09/19 at 11:44 AM. There was a tall rack with a tray of cottage cheese stored in several bowls. There was also a tray of pudding stored in bowls with whipped topping out at room temperature. There was no ice or refrigeration. -At 11:58 AM, the rack was observed with a tray full of seven bowls of cottage cheese and six bowls of pudding with whipped topping, out at room temperature. -At 12:21 PM, the Assistant Food Service Director (AFSD) #66 took the temperature of one bowl of cottage cheese. The temperature was 48.6 degrees Fahrenheit (F). She then disposed of the remaining cottage cheese. The Certified Dietary Manager (CDM) was interviewed on 01/10/19 at 9:45 AM. The stated the cold food items on the tray line should have had ice on it or stored in the refrigerator. Review of the Record of Food Temperatures policy on 01/14/19 at 7:39 AM, dated 11/27/17, revealed any cold food temperature above 41 degrees F requires corrective action. The cold food will be discarded. b) Equipment The kitchen was observed on 01/09/19 at 1:43 PM. Cook #127 was observed preparing the pureed texture. She was processing cabbage rolls. She placed one tray of processed cabbage rolls in the [NAME]ot Coupe (processor) container. When finished, she placed the [NAME]ot Coupe container with the blade and lid in the 2-pan sink. At 1:53 PM, she ran the water and took a cleaning rag out of the sanitizer bucket. She began cleaning the blade with the sanitizer rag at the same time rinsing under the running water. She laid the blade on parchment paper. She continued the same process with the [NAME]ot Coupe container. When asked about taking the [NAME]ot Coupe pieces to the dish machine, she stated that it was not dish washer safe. She did not use any detergent to clean the equipment. The sanitizer was rinsed off during the process of running underneath the water. The Certified Dietary Manager (CDM) #93 was interviewed on 01/09/19 at 3:08 PM. She stated there was no mention of the equipment being not dish washer safe throughout the manufacturer's guidelines. She stated they were not able to place the previous machine in the dish machine. This was a new machine and was able to be washed. She confirmed this staff member had not been washing the [NAME]ot Coupe parts with detergent. She had only been using the sanitizer. She acknowledged the sanitizer would have been rinsed off underneath the running water. The CDM was interviewed on 01/10/19 at 9:45 AM. All the cooks had been washing the equipment the same way. She informed the cook the day before that she needed to use the dish machine. She confirmed the equipment needed to be washed with detergent and then sanitized. Review of the (YEAR) Food Code by the Food and Drug Administration on 01/14/19 at 7:49 AM, page 142, revealed equipment food-contact surfaces and utensils shall be cleaned.",2020-09-01
1293,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-01-10,840,D,0,1,Z38R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a service contract with an outside service to provide [MEDICAL TREATMENT] services. This affected one (Resident #72) of one sampled resident reviewed for [MEDICAL TREATMENT]. The facility census was 180. Findings included: a) Resident #72 Review of the clinical record on 01/08/19 at 11:41 AM revealed an admission history form dated 12/29/18. The admission history documented Resident #72 was originally admitted to the facility on [DATE] with a readmission date of [DATE] following a [MEDICAL CONDITION] infarction. Resident #72 was originally admitted to the facility with a list of [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #72 had a Brief Interview for Mental Status (BIMS) of 10 out of 15 which documented moderate cognitive impairment. Resident #72 was independent with ambulation and needed supervision with his activities of daily living (ADLs). A physician's orders [REDACTED]. During the initial interview with Resident #72 on 01/07/19 at 10:05 AM, he stated that he was getting ready to go to his [MEDICAL TREATMENT] appointment. Resident #72 stated he goes to the Davita [MEDICAL TREATMENT] center. On 01/08/19 at 11:45 AM, Nursing Home Administrator (NHA) #256 was interviewed. NHA #256 stated the only contract the facility had was with a [MEDICAL TREATMENT] center other than Davita [MEDICAL TREATMENT] Center. NHA #256 stated that she was unaware that Resident #72 was going to the Davita center. On 01/08/19 at 11:55 AM, Licensed Practical Nurse (LPN) #230 was interviewed. LPN #230 confirmed Resident #72 received his [MEDICAL TREATMENT] from the Davita Center. On 01/08/19 at 12:03 PM, LPN #28 was interviewed. LPN #28 stated that as long as she had worked at the facility, Resident #72 had been receiving his [MEDICAL TREATMENT] at the Davita center.",2020-09-01
1294,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-01-10,880,D,0,1,Z38R11,"Based on observation and interview, the facility failed to ensure nursing staff used proper infection control techniques to prevent cross contamination to one (Resident #36) of five sampled residents observed being administered medications. The facility census was 180. Findings included: a) Resident #36 On 01/08/19 at 7:39 AM, Licensed Practical Nurse (LPN) #247 was observed as she set up a total of nine tablets/capsules for Resident # 36 at the medication cart. LPN #247 donned one glove on her left hand. She punched medications from medication cards or poured the tablets/capsules from bottles directly into her gloved hand in lieu of dropping or pouring the medications into the medication cup. While setting up the medications, LPN #247 contaminated her gloved hand by handling medication cards/bottles and opening/closing the medication cart drawers. At 7:50 AM on 01/08/19, the observation was reviewed with LPN #247. She was asked if the medication cart drawers and medication cards/bottles she had handled with her gloved hand would be considered clean. She stated she had wiped down the cart prior to starting the medication pass. LPN #247 did not address placing the medications in her contaminated gloved hand. At 8:03 AM on 01/08/19, the observation was reviewed with the Director of Nursing. She stated the LPN had probably not used good infection control practice by handling the medication with her contaminated gloved hand.",2020-09-01
1295,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,550,D,0,1,SW6S11,"Based on observation, record review, and staff interview the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. For Resident #[AGE], the facility failed to provide a dignified dining experience. This was a random opportunity for discovery. Resident identifier: #[AGE]. Facility census: 182. Findings include: a) Resident #[AGE] On 01/20/20 at 1:06 PM, Resident #[AGE] was observed to be placed by staff in the hallway of A-wing, near the entry door to her room. An over-the-bed table was placed in front of her. Resident #[AGE]'s lunch tray was placed and set up for her. Resident #[AGE] was observed to consume her lunch meal in the hallway. During an interview with Resident #[AGE] on 01/21/20 at 12:56 PM, Resident #[AGE] stated she did not want to eat in the hallway. She stated that staff had informed her that she could not eat in her room, since they were going to clean that room. Resident #[AGE] stated she does not like eating in the hallway. Resident #[AGE]'s Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/19 noted the resident had a score of Brief Interview for Mental Status (BI[CONDITION]) of 15. A BI[CONDITION] score of 15 is the highest score possible indicating that the resident is cognitively intact and has capacity. During the observation of the lunchtime meal on 01/21/20 at 1:07 PM, Resident #[AGE] did not have a tray. Employee #126, Registered Nurse (RN) / Assistant Director of Nursing (ADON), was overheard stating to the staff on A-wing that all trays had been passed. During an interview on 01/21/20 at 1:08 PM, ADON #126 was asked if all residents A-wing had been served lunch. ADON #126 responded that all residents had been served, with the exception of one resident who was currently out of the facility. ADON #126 was then asked why Resident #[AGE] did not receive a tray during the initial meal delivery on the unit. ADON #126 stated Resident #[AGE] eats in the dining room. After surveyor intervention, ADON #126 went to Resident #[AGE]'s room and asked Resident #[AGE] if she had eaten lunch, to which Resident #[AGE] responded that she had not received her lunch. On 01/21/20 at 1:11 PM, ADON #126 returned from getting Resident #[AGE]'s tray from the tray cart. Resident #[AGE]'s tray consisted of a Styrofoam to go container, instead of the ceramic plate and metal silverware that the remaining residents on A hall received. A review of Resident #[AGE]'s care plan did not reveal any requests and / or care planning for Resident #[AGE] to be served food on Styrofoam. On 01/22/20 at 8:14 AM, the findings were discussed with the Administrator. No further information was provided prior to the end of the survey on 0[DATE] at 11:00 AM.",2020-09-01
1296,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,558,E,0,1,SW6S11,"Based on observation and staff interview, the facility failed to ensure a call light was accessible and within reach for four (4) residents. This was a random opportunity for discovery. Resident identifiers: #12, #132, #58, and #137 Facility census: 176. Findings include: a) Resident #12 On 01/20/20 at 10:48 AM, Resident #12's call light was observed to be clipped behind the left side of the headboard, and hanging behind the headboard. This placement was approximately 10 inches out of the resident's reach. On 01/20/20 at 10:49 AM, the Director of Nursing (DON) was called into Resident #12's room. The DON placed the call light in reach of Resident #12. b) Resident #132 On 01/20/20 at 10:49 AM, Resident #132 was observed to be sitting in her wheelchair, at the end of her bed, close to the door. Resident #132's call light was lying across Resident #132's bed placed near the head of her bed. On 01/20/20 at 10:50 AM Employee #25, Nursing Assistant (NA), was asked to come into the room. NA # stated that she would place Resident #132's call light closer to her. c) Resident #58 On 01/20/20 at 10:49 AM, Resident #58 was observed to be sitting in her wheelchair, at the end of her bed, close to her closet. Resident #58's call light was lying across Resident #58's bed and placed near the head of her bed. On 01/20/20 at 10:50 AM Employee #25, Nursing Assistant (NA), was asked to come into the room. NA # stated that she would place Resident #58's call light closer to her. d) Resident #137 On 01/20/20 at 10:53 AM, Resident #137 was observed to be sitting on his bed, facing the closet. Resident #137's call light was observed to be lying behind the bed and against the wall. Resident #137 was sitting on his bed, facing the closet. On 01/20/20 at 10:55 AM, Employee #126, Assistant Director of Nursing / Registered Nurse (ADON / RN), was asked to come into Resident #137's room. RN #126 stated that she would place the call light near Resident #137. e) On 10/28/19 at 12:43 PM the findings for Residents #12, 132, 58, and 137 were discussed with the Administrator. No additional information was provided prior to the close of the survey on 0[DATE] at 11:00 AM.",2020-09-01
1297,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,584,E,0,1,SW6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview the facility failed to provide a safe and comfortable and home like environment. This failed practice had the potential to affect more than a limited number of residents residing at the facility. This was a random opportunity for discovery. Facility census 176. Findings included: a) Shower room B On 01/22/2020 at 9:45 AM, a tour of the shower room revealed exposed wood and whole on the base of the wall, from missing tile, thick black substance around the base of the toilet, storage cabinet was unlocked, visible build-up of debris along the walls and floor, shower curtains were soiled. b) Shower room C On 01/22/2020 at 10:00 AM, Tour of the shower room C revealed an unknown brown substance on the shower curtain, along with other unidentified debris on the curtain, Director of Nursing shown the shower curtain, the bench inside the shower had a black/brownish substance around the hole on the seat, used gloves and wash clothes on the floor, heavy build-up of black debris around the toilet and along the wall. On 01/22/2020 at 10:15 AM, Director of Environmental Services was asked about the cleanliness of the shower rooms and he replied, the rooms are old and cannot be cleaned well. He went on to say that his staff clean the shower rooms three times a day and that he checks them himself. He was shown the soiled curtains, and he said, The aides should have taken care of that and the things on the floor. He was asked about the vent on the ceiling having silver duct tape on it and his answer was, Well this is West Virginia and you know what they say if it don't move put WD-40 on it and if it moves put duct tape on it. He went on to say the staff cleans the shower rooms three (3) times a day. It was pointed out to him that the heavy debris was easily moved by my shoe. c) Shower room F On 01/22/2020 at 10:30 AM, the tub room had feces on the floor in front of the toilet, and around the toilet seat. Director of Nursing was in the shower room to witness the feces on the floor and on the toilet seat. She placed a sign on the door Closed for cleaning. d) Cosmetic imperfections During the initial tour on 01/20/20 at 11:30 AM, an observation of room [ROOM NUMBER] on C Hallway revealed a seven (7) inch area of damaged wall around the light located over the headboard of bed B and a small section of cove base was missing between the sink area and closet. In an interview with the Maintenance Supervisor on 01/21/20 at 3:40 PM, verified the damaged wall and the missing cove base needed to be repaired.",2020-09-01
1298,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,625,E,0,1,SW6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to provide residents and/or their responsible party notification of bed hold at the time of transfer/discharge to a hospital. This was true for 2 of 4 residents reviewed for hospitalization s. This practice had the potential to affect more than a limited number of residents. Resident identifier: #139 and #36. Facility census: 176. Findings included: a) Resident (R#139) On 01/21/20 at 02:17 PM, an interview with Nurse Unit manager #215 revealed the only thing the nurses send with the resident when they are transferred to the hospital is the orders, medication list, face sheet, advance directives, and SNF/NF to hospital transfer form. She said nurse do not do bed holds, the business office takes care of that. Nurse Unit manager #215 provided the resident's 12/02/19 INTERACT transfer forms. Review of the INTERACT transfer forms revealed the transfer and discharge notice given to R#139 does not refer to any information concerning a bed hold. An interview with the Admission Director and an Admission Coordinator (AC#258) on 01/21/20 at 02:35 PM, revealed a bed hold is offered to the resident the next day after being transferred to the hospital. Admission Director said sometimes a hospital doesn't keep them and they come right back here. When asked if the resident or family representative was sent and/or received any notice of a bed hold with in twenty-four (24) hours of the resident's hospitalization on [DATE]. AC#258 replied they attempt to contact the resident and/or the medical power of attorney (MPOA) within 24 hrs (twenty-four hours) and offer the bed hold, when or if they do not get anyone to speak with them, then they automatically mark declined on the bed hold form. The Admission Director stated it is all explained to a resident when they are first admitted to the facility, they go over all that and the information is in the admissions book they receive. AC#258 said, This resident's payment source was Medicaid, meaning the census would have to be at least 191 or 95% for Medicaid to even pay to hold the bed. An interview with the Administrator, on 01/22/20 at 10:35 AM, revealed the facility does try to keep the same room for the resident when they can. R#139 was transferred on 12/02/19 and had Medicaid. The census at that time was 1[AGE], much less than 95% needed for Medicaid to pay for a bed hold and the resident doesn't have the finances. R#139 was readmit on 12/06/19, by then another resident had already transition from the other side and the bed was filled. We know she was upset about not going back to her old room, but when a bed comes open on that hall we told her we would let her know and see if she wants to move back to that hall at that time. b) Resident #36 During a record review, Resident #36's medical record noted that she had been discharged from the facility on 12/24/19. A review of Resident #36's medical chart did not reveal any information related to a bed hold notice to the responsible party. During an interview on 01/22/20 at 3:18 PM with Employee #110, Admissions Director (AD), AD #110 stated that the bed hold policy is explained to the resident patient and / or their responsible party upon admission. After a resident is discharged from the facility, the admissions department attempts to contact the resident and / or their responsible party. The responsible party has 24 hours to accept and / or decline the bed hold. If a resident discharges on a weekend and / or holiday, the admissions department will contact the responsible party on the next business day. On 01/22/20 at 4:00 PM, AD #110 stated that she could not find the bed hold notice for Resident #36's discharge on 12/24/19. On 0[DATE] at 8:34 AM, the findings were discussed with the Administrator. No further information was provided prior to the end of the survey on 0[DATE] at 11:00 AM.",2020-09-01
1299,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,641,D,0,1,SW6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to accurately complete a comprehensive assessment for one (1) of thirty-five (35) Minimum Data Sets (MDS) reviewed during the investigation phase of the survey process. Resident #25 had a [DIAGNOSES REDACTED].#25 having no swallowing disorders. Resident identifier: #25. Facility census: 176. Findings included: a) Resident #25 A record review completed on 0120/20, revealed the Significant Change MDS with an annual reference date (ARD) of 10/16/19 did not code Resident #25 as having any swallowing difficulties. A review of the Care Plan had a Focus: Dysphagia with risk for aspiration and Interventions: Observe for coughing, shortness of breath, choking, labored respiration and lung congestion. Observe for difficulty swallowing, holding food in mouth. In an interview with the Corporate Nurse Consultant on 01/21/20 at 1:52 PM, verified the MDS did not accurately reflect any problems with swallowing or choking for Resident #25.",2020-09-01
1300,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,656,E,0,1,SW6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observations, record review, and staff interview the facility failed to implement a comprehensive care plan. Resident #91's care plan was not implemented related to falls. Resident #[AGE]'s care plan was not implemented related to Oxygen administration. Resident #91's care plan was not implemented related to respiratory care. Resident #95's care plan was not implemented with regard to communication. Resident #82's care plan was not implemented related to fistula care. Resident identifiers: #91, [AGE], 95, and 82. Facility census: 176. Findings include: a) Resident #91 (falls / accidents) On 01/20/20 at 12:36 PM, Resident #91's bathroom was toured. There were no skid strips placed in front of the toilet. On 01/20/20 at 12:37 PM, Employee #199, Social Worker, was asked to enter Resident #91's bathroom. SW #199 did not see any non-skid strips in front of Resident #91's toilet. A review of Resident #91's care plan revealed the following: Problem: -- At risk for falls due to: [MEDICAL CONDITION], Alzheimer's, Dementia,[MEDICAL CONDITION](hypertension), medication side effects, episodes of incontinence, and chronic pain. Goals associated with this problem include: -- Resident will have no falls with injury through next review. Interventions include: -- Non slip strips in front of toilet. On 01/22/20 at 8:14 AM, the findings were discussed with the Administrator. No further information was provided prior to the end of the survey on 0[DATE] at 11:00 AM. b) Resident #[AGE] On 01/22/20 at 12:54 PM, Resident #[AGE] was observed to be asleep in bed. Resident #[AGE]'s nasal canula was not in her nose, but rather lying on the bridge of her nose, close to her eyebrows. Resident #[AGE]'s concentrator was on a setting of 2.5 liters. On 01/22/20 at 12:55 PM, Employee #1[AGE], Licensed Practical Nurse (LPN) was called into Resident #[AGE]'s room. LPN #1[AGE] placed the nasal canula on Resident #[AGE]'s nose and stated that the oxygen setting should be at 2 liters. During an interview on 01/22/20 at 1:04 PM, Employee #120, LPN, was asked what the oxygen order for Resident #[AGE] was, as the order was not listed in the electronic medical record, the Medication Administration Record (MAR), the Treatment Administration Record (TAR), and Oxygen was care planned. LPN #120 stated Resident #[AGE] should have an order for [REDACTED]. On 01/22/20 at 1:07 PM, LPN #120 stated that she could not find an order for [REDACTED].#[AGE]'s electronic medical record. A review of Resident #[AGE]'s care plan revealed the following: Problem: -- Oxygen: Resident requires oxygen use Shortness of Breath, chronic [MEDICAL CONDITION]. Goals associated with the problem include: -- Resident will remain free from complications associated with oxygen use during the forthcoming quarter. Interventions included: -- Observe resident for shortness of breath (cyanosis of the lips and nail beds, increased confusion, nasal flaring, retractions, or tachypnea) and notify physician if noted. -- Provide oxygen as ordered A further review of Resident #[AGE]'s medical record noted that an order for [REDACTED]. A review of Resident #[AGE]'s MAR and TAR initially revealed no order for Oxygen listed. A second review of Resident #[AGE]'s MAR and TAR on 01/22/20 at 1:30 PM revealed an order for [REDACTED]. Moreover, an order audit report noted that the order for Oxygen had not been entered into the electronic medical record until 01/22/20 at 1:08 PM. On 01/22/20 at 2:53 PM, the findings were discussed with the Administrator. No further information was provided prior to the end of the survey on 0[DATE] at 11:00 AM. c) Resident #91 (respiratory care) On 01/20/20 at 11:18 AM, Resident #91's concentrator was observed to be setting on 5 liters. On 01/20/20 at 11:20 AM, Employee #151, Licensed Practical Nurse (LPN) was asked to come into the room and look at the concentrator. LPN #151 stated that the concentrator was set on 5 liters, but the ordered amount was 2 liters. A review of Resident #91's record revealed an order on 10/26/18: O2 (Oxygen) @ (at) 2LPM (liters per minute) prn (as needed) sat below 90% or Shortness of breath A review of Resident #91's care plan noted the following: Problem: -- Oxygen: Resident requires PRN oxygen use Shortness of Breath, [MEDICAL CONDITION] Goals associated with this problem included: -- Resident will remain free from complications associated with oxygen use during the forthcoming quarter. Interventions included: -- Provide oxygen as ordered On 01/21/20 at 8:34 AM, Resident #91's Oxygen concentrator was observed to be on a setting for 4 liters. On 01/21/20 at 8:34 AM, the Director of Nursing (DON) was asked to come to Resident #91's room. The DON stated that the concentrator was set to 4 liters and she adjusted the setting to 2 liters. On 01/22/20 at 8:14 AM, the findings were discussed with the Administrator. No further information was provided by the end of the survey on 0[DATE] at 11:00 AM. d) Resident #95 During a record review for Resident #95 on 01/20/20 revealed the care plan had a Focus: Resident has a communication problem related to impaired hearing. Resident has a [DIAGNOSES REDACTED]. Interventions: Use alternative communication tools as needed, such as communication book/board, writing pad. In an attempted interview with Resident #95 on 01/20/20 at 3:41 PM, it was discovered communication was very difficult due to her hearing loss. She wanted questions to be written down, but there was no communication board or writing pad present in her room. During an interview on 01/22/20 at 9:42 PM with Licensed Practical Nurse (LPN) #[AGE] reported Resident #95 refused to wear hearing aids or use an amplifier box. In an interview with Activities Director #[AGE] on 01/22/20 08:28 AM, reported he had provided a white board for Resident #95, but he verified the communication white board was not found in Resident #95's room. He replaced the white board and agreed the care plan was not being followed. e) Resident #82 Review of Resident #82's medical records found he was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #82's comprehensive care plan found he had a fistula in his left upper arm and the nursing staff was to check for thrill/bruit q shift, monitor for changes of temperature in the extremity, presence of blood at site or rupture of site (call 911) and notify MD. - 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). 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. No documentation of the resident's fistula daily could be found. During an interview on 01/21/20 at 12:00 pm with Employee #55, Direct Care Supervisor (DCD) and Employee #21, Assistant Director of Nursing (ADON), Resident #2[AGE]'s medical records were reviewed and found the nursing staff had not implemented the care plan for fistula monitoring. On 01/21/19 at 2:10 pm, the Director of Nursing (DON) and Nursing Home Administrator was informed of the above findings.",2020-09-01
1301,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,657,D,0,1,SW6S11,"Based on record review and staff interview the facility failed to revise a care plan. This failed practice had the potential to affect one (1) out of 35 residents reviewed for care plans. Resident identifiers: Resident # 35. Facility census 176. Findings included: a) Resident # 35 During a review of medical records it was discovered that Resident #35 had three (3) pressure injuries on a readmission on 01/06/2020. The nursing notes stated, that upon arrival she had one on the left and right heels and the lower left buttock. On 01/22/20 at 10:35 AM, Director of nursing was asked if she had any more information she could provide for the care plan. She agreed the information about the pressure injuries should have been revised.",2020-09-01
1302,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,684,E,0,1,SW6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was true for six (6) of thirty-five (35) sampled residents during the Long-term Care Survey Process (LTCSP). Resident identifiers: #104, #2[AGE], #6, #36 and #27. Facility census: 176. Findings include: a) Resident #104 Medical record review for Resident #104, reveals she was admitted to the facility on [DATE] from an acute care facility after receiving treatment for [REDACTED]. Admitting medications as directed by the discharge summary dated 09/28/19, included [MED] 10 milligrams (mg) daily,[MEDICATION NAME] mg twice daily, [MEDICATION NAME] 25 mg twice daily and [MEDICATION NAME] 0.3 mg three times daily. a.1.) [MED] Review of Resident #104's discharge summary, dated 09/28/19, found an order for [REDACTED].>Review of the September and October 2019 Medication Administration Record [REDACTED]. On 09/30/19, the consultant pharmacist recommendation read: [MED] 10 mg daily on discharge summary. Order entered into computer program (point click care (PCC) as [MED] 15 mg daily. On [DATE] order changed to, [MED] 10 mg twice daily. On 10/25/19, the consultant pharmacist recommendation read: [MED] 10 mg daily on discharge summary. Order changed to [MED] 10 mg twice daily. Discussed with the Assistant Director of Nursing (ADON) and Unit Managers to clarify order for [MED] dose with physician. On 10/25/19, order for [MED] 10 mg daily. a.2.)[MEDICATION NAME] Review of Resident #104's discharge summary, dated 09/28/19, found an order for [REDACTED].>On 09/30/19, the consultant pharmacist recommendation read:[MEDICATION NAME](Isorbide [MEDICATION NAME]) 30 mg twice daily on discharge summary. Order entered into computer program (point click care (PCC) as [MEDICATION NAME] 30 mg twice daily. This recommendation was not addressed until after this surveyor's intervention. a.3.) [MEDICATION NAME] Review of Resident #104's discharge summary, dated 09/28/19, found an order for [REDACTED].>On 09/30/19, the consultant pharmacist recommendation read: [MEDICATION NAME] 25 mg twice daily on discharge summary. Order entered into computer program (point click care (PCC) as [MEDICATION NAME] 12.5 mg twice daily. On [DATE] order changed to [MEDICATION NAME] 25 mg twice daily. a.4) [MEDICATION NAME] ([MEDICATION NAME]) Review of Resident #104's physician orders [REDACTED]. 09/28/19- [MEDICATION NAME] ([MEDICATION NAME]) 0.3 mg three times daily for hypertension. 09/30/19- Order changed to [MEDICATION NAME] ([MEDICATION NAME]) 0.3 mg three times daily for hypertension; administer only if systolic blood pressure (B/P) is greater than 150. 10/10/19- Order change to [MEDICATION NAME] ([MEDICATION NAME]) 0.3 mg three times daily for hypertension; Hold if systolic blood pressure (B/P) is less than 150. Review of Resident #104's Medication Administration Record [REDACTED] No blood pressures recorded from 10/01/19 through 10/10/19 at 6am, 2pm and 10 pm. On the following dates and times the [MEDICATION NAME] ( [MEDICATION NAME]) was administered when the medication should have been held: At 6am on 10/13/19- b/p 136/70 and 10/19/19- b/p 136/51 At 2pm on 10/11/19- b/p- 138/[AGE]; [DATE]- b/p 149/81; 10/19/19- b/p 136/[AGE]; 10/25/19 b/p 134/[AGE] and 10/30/19 b/p-129/[AGE]. At 10 pm on 10/12/19- b/p 142/71; 10/28/19- b/p 142/78; and 10/31/19 b/p- 132/62 Review of November 2019 MAR found on the following dates and times the [MEDICATION NAME] ( [MEDICATION NAME]) was administered when the medication should have been held: At 6am on [DATE]- b/p- 128/63; 11/5/19- b/p 114/70; and 11/6/19- b/p 130/74. At 10 pm on [DATE]- b/p 135/64; 11/4/19 - b/p 110/64; and 11/5/19- b/p 126/[AGE]. a.5.) Blood sugars Review of Resident #104's medical records found an order dated 09/29/19 which read: Blood sugar checks before meals and at night ( 6:30 am, 11:30 am, 4:30 pm and 8:00 pm). Standing orders for diabetes mellitus (blood sugars) as follows: Step 1: Perform BS. If BS as needed Step 2: Wait 15 minutes. Recheck BS. If level still below target, give another 15 g of glucose or CHO. Once BS in normal range arrange for resident to have meal/snack which includes a protein, CHO and fat (i.e. sandwich). as needed. Step 3: If BS as needed. Step 4: Monitor resident for relative hypo/[MEDICAL CONDITION] for interventions. as needed Step 5: Notify physician if blood glucose less than [AGE]mg/dl or over 400mg/dl. Review of the October 2019 MAR found no blood sugars documented for 10/01/19 through 10/10/19. On 10/31/19 at 8 pm was blood sugar was 426. No documentation the physician was notified. Review of the November 2019 MAR found on [DATE] at 4 pm blood sugar was 518 and on 12/22/19 at 4 pm blood sugar was 429. No documentation found the physician was notified of blood sugars greater than 400 on [DATE] and 12/22/19. Review of the January 2020 MAR found: -- 01/13/20 at 6 am blood sugar 58. -- 01/17/20 at 6 am blood sugar 56. -- 01/19/20 at 6 am blood sugar 58. No documentation the physician was notified could be found. During an interview on 01/22/20 at 11:00 am with Employee #55, Direct Care Supervisor (DCD) and Employee #21, Assistant Director of Nursing (ADON), Resident #104's medical records were reviewed and found the above mentioned physician orders [REDACTED]. On 01/22/19 at 2:10 pm, the Director of Nursing (DON) and Nursing Home Administrator was informed of the above findings. b) Resident #2[AGE] Review of Resident #2[AGE]'s medical records found she was admitted to the facility on [DATE] with a urinary catheter for the treatment of [REDACTED]. Further review, found a progress note dated 01/14/20 at 5:46 pm and written by Employee #255, Registered Nurse (RN) which read: Entered resident's room for foley catheter care and treatments. No foley catheter in place at this time. Orders discontinued. On 01/17/20 at 10:38 am progress note written by Employee #21, Assistant Director of Nursing (ADON) read: Spoke with gynecologist's office regarding residents foley catheter being removed. Per office staff, the doctor removed the catheter during appointment on the 01/14/2020. Resident is voiding without difficulty at this time. During an interview on 01/22/20 at 11:00 am with Employee #55, Direct Care Supervisor (DCD) and Employee #21, Assistant Director of Nursing (ADON), Resident #2[AGE]'s medical records were reviewed and found the nursing staff was unable to determine when the foley catheter was removed at the time the foley catheter orders were discontinued. The ADON stated she was informed on 01/17/20 of the orders for the catheter was discontinued and no indications when it had been removed. On 01/22/19 at 2:10 pm, the Director of Nursing (DON) and Nursing Home Administrator was informed of the above findings. c) Resident #6 Review of Resident #6's medical records revealed he had a sacral pressure ulcer which had been present since his admission to the facility on [DATE]. Further review of Resident #6's medical records revealed he had Weekly Licensed Nurse Skin Evaluations performed. The weekly skin evaluations contained the question, Any existing ulcers (previously identified)? If the response to this question was yes, the location(s) and description(s) of the existing ulcers was to be documented. On two (2) of Resident #6's weekly skin evaluations, dated 01/04/20 and 01/18/20, the response to the question, Any existing ulcers (previously identified)? was No. During an interview on 01/22/20 at 3:40 PM, Unit Manager #220 agreed Resident #6's weekly skin evaluations performed on 01/04/20 and 01/18/20 should have responded Yes to the question, Any existing ulcers (previously identified)? and should have documented the location and description of the resident's sacral pressure ulcer. d) Resident #27 During initial screening process on 01/20/2020 at 12:02 PM, observation was made of Resident #27 setting on edge of bedside with bilateral lower extremities (BLE) dangling. At that time, it was noted that the Resident did not have any type of a wound dressing or [MEDICAL CONDITION] wraps in place on her bilateral lower extremities. On 01/20/20 at 3:38 PM record review indicated an active physician's orders [REDACTED]. Record review revealed on 01/21/2020 at 3:37 AM a treatment administration noted was entered by LPN #112 that documenting the [MEDICAL CONDITION] wraps had been removed by the resident, with no indication that any corrective measure was taken to re-apply the wraps at that time. On 01/22/2020 at 10:56 AM, Licensed Practical Nurse (LPN) #253 verified [MEDICAL CONDITION] wraps were not on place on the Resident's Bilateral Lower Extremities, as ordered. LPN #253 entered a progress note at 11:04 AM that stated, This nurse noted that resident did not have [MEDICAL CONDITION] wraps on this shift. At 11:25 AM on 01/22/2020, Wound Care Nurse #255 also verified the [MEDICAL CONDITION] were not in place and stated, They are scheduled to be changed today, I will see they get put on. At 11:27 AM on 01/22/2020 the Resident stated she removed the wraps over the weekend that were indicated on the Treatment Administration Record to have been applied on 01/19/2020. The Resident stated, I took those off they itch my legs. I knew they would be back in sometime to put them on. e) Resident #36 A review of Resident #36's medical record revealed that on 0[DATE], there was a physician's orders [REDACTED]. A further review of Resident #36's medical record noted the following weights entered: -- 8/7/2019 12:19 295.2 Lbs -- 7/8/2019 11:12 2[AGE].6 Lbs -- 6/3/2019 11:40 291.2 Lbs -- 5/7/2019 09:53 2[AGE].0 Lbs -- 4/3/2019 11:39 281.4 Lbs During an interview with the Director of Nursing (DON), on 01/22/20 at 8:28 AM, the DON was asked why weights were obtained for Resident #36 after the order to discontinue weights. The DON could not say why weights were obtained for Resident #36. The DON was asked if there a physician's orders [REDACTED]. The DON stated that there was not a new order to obtain weights for Resident #36. On 01/22/20 at 2:53 PM, the findings were discussed with the Administrator. No further information was provided prior to the end of the survey on 0[DATE] at 11:00 AM.",2020-09-01
1303,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,689,D,0,1,SW6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to ensure the environment was free from accidents and hazards. These occurrences were a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifiers: #27, #137. Facility census: 176. Findings included: a) Resident #27 On 01/22/2020 at 10:56 AM, observation was made a of bottle of Nature's Bounty L-[MEDICATION NAME] 1000 mg Vitamin Supplement (L-[MEDICATION NAME] is a chemical building block amino acid used to cardiovascular conditions and erectile dysfunction) lying in the bed with the resident, on the Resident's left side near her hand while the resident was sleeping. At 10:57 AM on 01/22/2020, Licensed Practical Nurse (LPN) #253 was called into the Resident's room and stated the medication (Vitamin Supplement) did not belong to the facility, and she was unaware the resident had it in her room. The bottle of Vitamin Supplement contained 15 tablets as verified by LPN #253. The Resident did not have an active order the Vitamin Supplement, and the Vitamin Supplement was removed by LPN #253 and placed at the nurse's station. The resident stated she had not taken of the medication; however, she did take at home and wanted to ask the Doctor about taking it while in the facility. At 11:20 AM on 01/22/2020 a list of Residents the facility considered to be Wanderers for building #1 Wings E,F,G, that could have potentially accessed the Vitamin Supplement was provided by RN #55 to include Resident #41, Resident #13, Resident #152. Record review indicated a progress note was entered by LPN #253 on 01/22/2020 at 11:49 AM that stated, Resident noted to have a bottle of L-[MEDICATION NAME] 1000 mg in her bed shift. Educated resident on not taking her own medications or keeping medications in her room. Bottle of medication was taken and added to medication list per physician orders [REDACTED]. Review of the facility's Medication Storage policy stated Bedside Medications must be stored in a locked area and have a written doctor's order in the medical record, with special care taken to ensure other residents do not have access to bedside medications. b) Resident #137 On 01/20/20 at 10:53 AM, Resident #137 was observed sitting on his bed, with his over-the-bed table in front of him. On his over-the-bed table was a basin of soapy water, containing what appeared to be foam from shaving cream as well as four (4) used razors. There was no staff member present in Resident #137's room. On 01/20/20 at 10:55 AM, Employee #126, Assistant Director of Nursing (ADON) / Registered Nurse (RN) was asked to enter Resident #137's room. ADON #126 stated that there was no staff in the room, but the staff must have been shaving him. ADON #126 stated that she would removed the razors and dispose of them in a sharps container. A review of the facility's policy entitled, Standard Precautions Infection Control Protocol noted the following: Component: Needles and Other Sharps Practices: Do not recap, bend, break, or hand-manipulate used needles; if recapping is required, use a one-handed scoop technique only; use safety features when available; place used sharps in puncture-resistant container. On 01/20/20 at 1:20 PM, the facility provided a list of all wandering residents for Building 2. The facility listed two residents: Resident #128 and #28. Also, during a record review, Resident #70 was noted to be care planned for wandering. Resident #128 was identified by the facility as a resident who wanders. A review of Resident #128's care plan revealed the following: Problem: -- Problematic behavior in which resident acts characterized by inappropriate behavior; Rummaging through other resident's personal items, office door decor and other miscellaneous items related to: Cognitive impairment moderate intellectual disabilities. Goal associated with the problem include: -- All items belonging to other residents are returned. Interventions associated with the problem include: -- Alert staff to resident's history of wandering behaviors. -- Monitor residents room and return items / belongings to other residents; discard food. Resident #28 was identified by the facility as a resident who wanders. A review of Resident #28's care plan revealed the following: Problem: -- Resident is at risk for elopement from the facility. Dementia and cognitive impairment. Goals associated with the problem include: -- Resident will not elope from the facility through next review period. Interventions associated with the problem include: -- Alert staff to resident's history of wandering behaviors. -- Attempt to keep resident in an area where frequent observation is possible. During a record review, it was revealed that Resident #70 also wanders. Resident #70 was not identified on the document that the facility provided. A review of Resident #70's care plan revealed the following Problem: --Resident is at risk for elopement related to exit seeking, and wandering. Goal: Resident will not elope from the facility through the next review period. Interventions included: -- Attempt to keep resident in an area where frequent observation is possible. On 01/22/20 at 8:14 AM, the findings were discussed with the Administrator. No further information was provided by the end of the survey on 0[DATE] at 11:00 AM.",2020-09-01
1304,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,695,E,0,1,SW6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to provide respiratory services within professional standards of care. Resident #[AGE] was administered Oxygen without a physician's orders [REDACTED]. Resident #27. Resident identifiers: #[AGE], 91, and 27. Facility census: 176. Findings include: a) Resident #[AGE] On 01/22/20 at 12:54 PM, Resident #[AGE] was observed to be asleep in bed. Resident #[AGE]'s nasal cannula was not in her nose, but rather lying on the bridge of her nose, close to her eyebrows. Resident #[AGE]'s concentrator was on a setting of 2.5 liters. On 01/22/20 at 12:55 PM, Employee #1[AGE], Licensed Practical Nurse (LPN) was called into Resident #[AGE]'s room. LPN #1[AGE] placed the nasal cannula on Resident #[AGE]'s nose and stated that the oxygen setting should be at 2 liters. During an interview on 01/22/20 at 1:04 PM, Employee #120, LPN, was asked what the oxygen order for Resident #[AGE] was, as the order was not listed in the electronic medical record, the Medication Administration Record (MAR), the Treatment Administration Record (TAR), and Oxygen was care planned. LPN #120 stated Resident #[AGE] should have an order for [REDACTED]. On 01/22/20 at 1:07 PM, LPN #120 stated that she could not find an order for [REDACTED].#[AGE]'s electronic medical record. A review of Resident #[AGE]'s care plan revealed the following: Problem: -- Oxygen: Resident requires oxygen use Shortness of Breath, chronic [MEDICAL CONDITION]. Goals associated with the problem include: -- Resident will remain free from complications associated with oxygen use during the forthcoming quarter. Interventions included: -- Observe resident for shortness of breath (cyanosis of the lips and nail beds, increased confusion, nasal flaring, retractions, or tachypnea) and notify physician if noted. -- Provide oxygen as ordered A further review of Resident #[AGE]'s medical record noted that an order for [REDACTED]. A review of Resident #[AGE]'s MAR and TAR initially revealed no order for Oxygen listed. A second review of Resident #[AGE]'s MAR and TAR on 01/22/20 at 1:30 PM revealed an order for [REDACTED]. Moreover, an order audit report noted that the order for Oxygen had not been entered into the electronic medical record until 01/22/20 at 1:08 PM. A review of the facility's policy entitled, Oxygen Concentrator noted the following: Oxygen should be administered only under orders of the attending physician, except in the case of an emergency. 1. Care of the Resident - a. Obtain physician's orders [REDACTED]. f. Turn the unit on to the desired flow rate and assess for proper functioning . On 01/22/20 at 2:53 PM, the findings were discussed with the Administrator. No further information was provided prior to the end of the survey on 0[DATE] at 11:00 AM. b) Resident #91 On 01/20/20 at 11:18 AM, Resident #91's concentrator was observed to be setting on 5 liters. On 01/20/20 at 11:20 AM, Employee #151, Licensed Practical Nurse (LPN) was asked to come into the room and look at the concentrator. LPN #151 stated that the concentrator was set on 5 liters, but the ordered amount was 2 liters. A review of Resident #91's record revealed an order on 10/26/18: O2 (Oxygen) @ (at) 2LPM (liters per minute) prn (as needed) sat below 90% or Shortness of breath, every shift A review of Resident #91's care plan noted the following: Problem: -- Oxygen: Resident requires PRN oxygen use Shortness of Breath, [MEDICAL CONDITION] Goals associated with this problem included: -- Resident will remain free from complications associated with oxygen use during the forthcoming quarter. Interventions included: -- Provide oxygen as ordered On 01/21/20 at 8:34 AM, Resident #91's Oxygen concentrator was observed to be on a setting for 4 liters. On 01/21/20 at 8:34 AM, the Director of Nursing (DON) was asked to come to Resident #91's room. The DON stated that the concentrator was set to 4 liters and she adjusted the setting to 2 liters. A review of the facility's policy entitled, Oxygen Concentrator noted the following: Oxygen should be administered only under orders of the attending physician, except in the case of an emergency. 1. Care of the Resident - a. Obtain physician's orders [REDACTED]. f. Turn the unit on to the desired flow rate and assess for proper functioning . On 01/22/20 at 8:14 AM, the findings were discussed with the Administrator. No further information was provided by the end of the survey on 0[DATE] at 11:00 AM. c) Resident #27 On 01/20/20 at 11:30 AM Supplemental Oxygen was observed to be in use by the Resident at 2 liters via nasal canula. Record Review on 01/20/2020 at 2:46 PM indicated an incomplete Order for oxygen that stated, (typed as written): Oxygen at L NC d/t SOB. Check O2 sats q shift and prn. The order did not have desired liter flow specified. During an interview on 01/21/20 at 2:05 PM regarding incomplete Oxygen order, Registered Nurse (RN) #231 stated, Yea that's not good. When RN #231 was asked how he verified liter flow when none was specified on order he stated, I checked the O2 sat, that is what comes up to do on my task. But you are right, the liter flow setting is not specified. On 01/21/20 at 3:15 PM, the Director of Nursing (DON) verified and agreed the O2 order was incomplete and did not specify a liter flow for use. The DON stated they (nursing staff) will call the Doctor and get it (oxygen order) verified with the correct liter flow added. Review of the facility's Oxygen Concentrator policy stated to Obtain physician's orders [REDACTED].).",2020-09-01
1305,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,698,D,0,1,SW6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that residents who require [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was true for one (1) of one (1) residents reviewed for [MEDICAL TREATMENT]. Resident identifier: #82. Facility census: 176. Findings include: Review of Resident #82's medical records found he was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #82's comprehensive care plan found he had a fistula in his left upper arm and the nursing staff was to check for thrill/bruit q shift, monitor for changes of temperature in the extremity, presence of blood at site or rupture of site (call 911) and notify MD. - 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). 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. No documentation of the resident's fistula daily could be found. During an interview on 01/21/20 at 12:00 pm with Employee #55, Direct Care Supervisor (DCD) and Employee #21, Assistant Director of Nursing (ADON), Resident #2[AGE]'s medical records were reviewed and found the nursing staff not monitored the fistula daily as indicated. On 01/21/19 at 2:10 pm, the Director of Nursing (DON) and Nursing Home Administrator was informed of the above findings.",2020-09-01
1306,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,755,E,0,1,SW6S11,"Based on record review, observation, and staff interview the facility failed to conduct appropriate reconciliation of a controlled substance at shift change for two (2) of two (4) medication carts reviewed for medication storage. This failed practice had the potential to affect more than an isolated number of residents. Facility Census: 176. Findings included: a) Medicaton Cart E Wing Even During observation of E wing even Medication Cart on 01/22/2020 at 8:49 AM, the Narcotic and Controlled substance shift count sheet was reviewed and found to be non-compliant. The Narcotic and Controlled substance shift count sheet was not completed and co-singed by both nurses (nurse coming on duty, nurse going off duty) for a total of thirteen (7) times for the time frame of 12/22/19 through 01/22/2020. Licensed Practical Nurse (LPN) #253 verified the records were incomplete for Medication Cart E Wing even, and that was the way the nursing staff verifies the narcotic/controlled substance to be accurate and accounted for at the end of each shift. The Narcotic and Controlled substance shift count sheet was incomplete for the following time slots: --12/22/19: 7A-7P - On Going Nurse --12/22/19: 7A-7P - Off Going Nurse --12/24/19: 7P-7A - On Going Nurse --12/25/19: 7A-7P - Off Going Nurse --12/30/19: 7A-7P - Off Going Nurse --01/13/20: 7P-7A - Off Going Nurse --[DATE]: 7A-7P - Off Going Nurse b) Medication Cart F Wing Even During observation of F wing even Medication Cart on 01/22/2020 at 900 AM, the Narcotic and Controlled substance shift count sheet was reviewed and found to be non-compliant. The Narcotic and Controlled substance shift count sheet was not accurately completed and co-signed by both nurses (nurse going off duty, nurse coming on duty) for a total of seventeen (7) times for the frame of [DATE] through 01/22/20. Inaccurate Narcotic and Controlled substance shift count sheet was verified as inaccurate by Licensed Practical Nurse (LPN) #253. The Narcotic and Controlled substance shift count sheet was incomplete for the following time slots: --[DATE]: 7P-7A - On Going Nurse --12/11/19: 7P-7A - Off Going Nurse --12/14/19: 7P-7A - On Going Nurse --12/15/19: 7P-7A - Off Going Nurse --12/29/30: 7P-7A - On Going Nurse --12/30/19: 7P-7A - Off Going Nurse --01/17/20: 7P-7A - Off Going Nurse c) Staff Interview At 9:10 AM on 01/22/2020 the Director of Nursing (DON) verified Narcotic and Controlled substance shift count sheets to be non-compliant and incomplete. The DON stated the expectations were for the Narcotic and Controlled substance shift count sheet to be signed at every shift change by the nurses for all medication carts in order to verify controlled substance/narcotic counts were correct upon leaving shift. d) Record Review Review of Controlled Substances policy provided by the DON stated: A scheduled reconciliation of controlled substance inventory should be maintained, and documented as required by state regulations (i.e. shift count practice).",2020-09-01
1307,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,756,D,0,1,SW6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record, policy review and staff interview, the facility failed to the consultant pharmacist followed the process and steps that must be taken when he or she identifies an irregularity that requires urgent action to protect the resident. Resident identifier: #104. Facility census: 176. Findings include: a) Resident #104 Medical record review for Resident #104, reveals she was admitted to the facility on [DATE] from an acute care facility after receiving treatment for [REDACTED]. Admitting medications as directed by the discharge summary dated 09/28/19, included [MED] 10 milligrams (mg) daily,[MEDICATION NAME] mg twice daily, [MEDICATION NAME] 25 mg twice daily and [MEDICATION NAME] 0.3 mg three times daily. a.1.) [MED] Review of Resident #104's discharge summary, dated 09/28/19, found an order for [REDACTED].>Review of the September and October 2019 Medication Administration Record [REDACTED]. On 09/30/19, the consultant pharmacist recommendation read: [MED] 10 mg daily on discharge summary. Order entered into computer program (point click care (PCC) as [MED] 15 mg daily. On [DATE] order changed to, [MED] 10 mg twice daily. On 10/25/19, the consultant pharmacist recommendation read: [MED] 10 mg daily on discharge summary. Order changed to [MED] 10 mg twice daily. Discussed with the Assistant Director of Nursing (ADON) and Unit Managers to clarify order for [MED] dose with physician. On 10/25/19, order for [MED] 10 mg daily. a.2.)[MEDICATION NAME] Review of Resident #104's discharge summary, dated 09/28/19, found an order for [REDACTED].>On 09/30/19, the consultant pharmacist recommendation read:[MEDICATION NAME](Isorbide [MEDICATION NAME]) 30 mg twice daily on discharge summary. Order entered into computer program (point click care (PCC) as [MEDICATION NAME] 30 mg twice daily. This recommendation was not addressed until after this surveyor's intervention. a.3.) [MEDICATION NAME] Review of Resident #104's discharge summary, dated 09/28/19, found an order for [REDACTED].>On 09/30/19, the consultant pharmacist recommendation read: [MEDICATION NAME] 25 mg twice daily on discharge summary. Order entered into computer program (point click care (PCC) as [MEDICATION NAME] 12.5 mg twice daily. On [DATE] order changed to [MEDICATION NAME] 25 mg twice daily. a.4) [MEDICATION NAME] ([MEDICATION NAME]) Review of Resident #104's physician orders [REDACTED]. 09/28/19- [MEDICATION NAME] ([MEDICATION NAME]) 0.3 mg three times daily for hypertension. 09/30/19- Order changed to [MEDICATION NAME] ([MEDICATION NAME]) 0.3 mg three times daily for hypertension; administer only if systolic blood pressure (B/P) is greater than 150. 10/10/19- Order change to [MEDICATION NAME] ([MEDICATION NAME]) 0.3 mg three times daily for hypertension; Hold if systolic blood pressure (B/P) is less than 150. Review of Resident #104's Medication Administration Record [REDACTED] No blood pressures recorded from 10/01/19 through 10/10/19 at 6am, 2pm and 10 pm. On the following dates and times the [MEDICATION NAME] ( [MEDICATION NAME]) was administered when the medication should have been held: At 6am on 10/13/19- b/p 136/70 and 10/19/19- b/p 136/51 At 2pm on 10/11/19- b/p- 138/[AGE]; [DATE]- b/p 149/81; 10/19/19- b/p 136/[AGE]; 10/25/19 b/p 134/[AGE] and 10/30/19 b/p-129/[AGE]. At 10 pm on 10/12/19- b/p 142/71; 10/28/19- b/p 142/78; and 10/31/19 b/p- 132/62 Review of November 2019 MAR found on the following dates and times the [MEDICATION NAME] ( [MEDICATION NAME]) was administered when the medication should have been held: At 6am on [DATE]- b/p- 128/63; 11/5/19- b/p 114/70; and 11/6/19- b/p 130/74. At 10 pm on [DATE]- b/p 135/64; 11/4/19 - b/p 110/64; and 11/5/19- b/p 126/[AGE]. Review of the Medication Regimen Review (MRR) Time Frame Policy read: Irregularity that requires urgent action. When the Consultant Pharmacist identifies an irregularity that requires immediate or urgent action, the Pharmacist should notify the Nursing Administration and the assigned nurse at the time the irregularity is identified. Nursing staff and/or Consultant Pharmacist should notify the provider immediately for action. During an interview on 01/22/20 at 11:00 am with Employee #55, Direct Care Supervisor (DCD) and Employee #21, Assistant Director of Nursing (ADON), Resident #104's medical records were reviewed and found the above mentioned physician orders [REDACTED]. No further information provided. On 01/22/19 at 2:10 pm, the Director of Nursing (DON) and Nursing Home Administrator was informed of the above findings.",2020-09-01
1308,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,757,D,0,1,SW6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs and without adequate monitoring of physician ordered parameters. Resident identifier: 104. Facility census: 176. Findings include: a) Resident #104 Medical record review for Resident #104, reveals she was admitted to the facility on [DATE] from an acute care facility after receiving treatment for [REDACTED]. Admitting medications as directed by the discharge summary dated 09/28/19, included [MED] 10 milligrams (mg) daily,[MEDICATION NAME] mg twice daily, [MEDICATION NAME] 25 mg twice daily and [MEDICATION NAME] 0.3 mg three times daily. a.1.) [MED] Review of Resident #104's discharge summary, dated 09/28/19, found an order for [REDACTED].>Review of the September and October 2019 Medication Administration Record [REDACTED]. On 09/30/19, the consultant pharmacist recommendation read: [MED] 10 mg daily on discharge summary. Order entered into computer program (point click care (PCC) as [MED] 15 mg daily. On [DATE] order changed to, [MED] 10 mg twice daily. On 10/25/19, the consultant pharmacist recommendation read: [MED] 10 mg daily on discharge summary. Order changed to [MED] 10 mg twice daily. Discussed with the Assistant Director of Nursing (ADON) and Unit Managers to clarify order for [MED] dose with physician. On 10/25/19, order for [MED] 10 mg daily. a.2.)[MEDICATION NAME] Review of Resident #104's discharge summary, dated 09/28/19, found an order for [REDACTED].>On 09/30/19, the consultant pharmacist recommendation read:[MEDICATION NAME](Isorbide [MEDICATION NAME]) 30 mg twice daily on discharge summary. Order entered into computer program (point click care (PCC) as [MEDICATION NAME] 30 mg twice daily. This recommendation was not addressed until after this surveyor's intervention. a.3.) [MEDICATION NAME] Review of Resident #104's discharge summary, dated 09/28/19, found an order for [REDACTED].>On 09/30/19, the consultant pharmacist recommendation read: [MEDICATION NAME] 25 mg twice daily on discharge summary. Order entered into computer program (point click care (PCC) as [MEDICATION NAME] 12.5 mg twice daily. On [DATE] order changed to [MEDICATION NAME] 25 mg twice daily. a.4) [MEDICATION NAME] ([MEDICATION NAME]) Review of Resident #104's physician orders [REDACTED]. 09/28/19- [MEDICATION NAME] ([MEDICATION NAME]) 0.3 mg three times daily for hypertension. 09/30/19- Order changed to [MEDICATION NAME] ([MEDICATION NAME]) 0.3 mg three times daily for hypertension; administer only if systolic blood pressure (B/P) is greater than 150. 10/10/19- Order change to [MEDICATION NAME] ([MEDICATION NAME]) 0.3 mg three times daily for hypertension; Hold if systolic blood pressure (B/P) is less than 150. Review of Resident #104's Medication Administration Record [REDACTED] No blood pressures recorded from 10/01/19 through 10/10/19 at 6am, 2pm and 10 pm. On the following dates and times the [MEDICATION NAME] ( [MEDICATION NAME]) was administered when the medication should have been held: At 6am on 10/13/19- b/p 136/70 and 10/19/19- b/p 136/51 At 2pm on 10/11/19- b/p- 138/[AGE]; [DATE]- b/p 149/81; 10/19/19- b/p 136/[AGE]; 10/25/19 b/p 134/[AGE] and 10/30/19 b/p-129/[AGE]. At 10 pm on 10/12/19- b/p 142/71; 10/28/19- b/p 142/78; and 10/31/19 b/p- 132/62 Review of November 2019 MAR found on the following dates and times the [MEDICATION NAME] ( [MEDICATION NAME]) was administered when the medication should have been held: At 6am on [DATE]- b/p- 128/63; 11/5/19- b/p 114/70; and 11/6/19- b/p 130/74. At 10 pm on [DATE]- b/p 135/64; 11/4/19 - b/p 110/64; and 11/5/19- b/p 126/[AGE]. Review of the Medication Regimen Review (MRR) Time Frame Policy read: Irregularity that requires urgent action. When the Consultant Pharmacist identifies an irregularity that requires immediate or urgent action, the Pharmacist should notify the Nursing Administration and the assigned nurse at the time the irregularity is identified. Nursing staff and/or Consultant Pharmacist should notify the provider immediately for action. During an interview on 01/22/20 at 11:00 am with Employee #55, Direct Care Supervisor (DCD) and Employee #21, Assistant Director of Nursing (ADON), Resident #104's medical records were reviewed and found the above mentioned physician orders [REDACTED]. No further information provided. On 01/22/19 at 2:10 pm, the Director of Nursing (DON) and Nursing Home Administrator was informed of the above findings.",2020-09-01
1309,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,761,E,0,1,SW6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. Five (5) of 11 multi-dose [MED]s located in the C-hallway and D-hallway medication carts were not dated to indicate when the medications were first opened. Residents identifiers: #14, #25, #120, #158, #40. Facility census: 176. Findings included: a) D-hallway medication cart On 01/21/20 at 8:00 AM, inspection of the D-hallway medication cart was conducted with Licensed Practical Nurse (LPN) #256. Two (2) of seven (7) multi-dose [MED]s located in the cart were not dated to indicate when they were first opened. These [MED]s were a multi-dose vial of Novalog [MED] for Resident #120 and a Tresiba [MED] Pen-Injector, which appeared to be empty, for Resident #40. Additionally, one (1) of seven (7) multi-dose [MED]s located in the D-hallway medication cart appeared to have been dated, but the writing had smeared, and the date was no longer legible. This [MED] was a multi-dose vial of Novalog [MED] for Resident #158. It is important to label multi-dose medications with the opening date because they must be discarded within 28 days of opening, unless the manufacturer specifies a different time frame for that medication. This is an infection control measure to decrease the risk of contamination of the medication vial and bacterial or fungal growth in the vial. LPN #256 verified the multi-dose [MED]s for Residents #120 and #40 were not dated when opened. She also verified the opening date for Resident #158's multi-dose [MED] was no longer legible. b) C-hallway medication cart On 01/21/20 at 1:52 PM, inspection of the C-hallway medication cart was conducted with Licensed Practical Nurse (LPN) #257. Two (2) of four (4) multi-dose [MED]s located in the cart were not dated to indicate when they were first opened. These [MED]s were a [MEDICATION NAME]Pen-injector for Resident #25 and a [MED] [MED] Pen-Injector for Resident #14. LPN #257 verified the multi-dose [MED]s for Residents #25 and #14 were not dated when opened. The facility's Administrator was informed of the above findings on 01/21/20 at 2:10 PM, and no further information related to the deficient practice was provided by the end of the survey. c) Policy The facility's policy entitled, Dating and Discarding of multidose [MEDICATION NAME] vials with effective date 06/21/17 stated, When initially entering a multidose vial, nursing staff shall date the vial when first entered.",2020-09-01
1310,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,804,D,0,1,SW6S11,"Based on observation, record review, and staff interview the facility failed to ensure each resident was provided that is palatable, attractive, and at a safe and appetizing temperature. For Resident #[AGE], the facility failed to provide food was that was an an appetizing temperature. This was a random opportunity for discovery. Resident identifier: #[AGE]. Facility census: 176. Findings include: a) Resident #[AGE] During an interview on 01/21/20 at 8:35 AM, Resident #[AGE] stated that food is not always appealing. Resident #[AGE] stated that sometimes the temperatures of the food is not what it is supposed to be. Resident #[AGE] noted that sometimes food that was supposed to be hot was somtimes cold and that food that is supposed to be cold is actually warm. Resident #[AGE]'s Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/19 noted the resident had a score of Brief Interview for Mental Status (BI[CONDITION]) of 15. A BI[CONDITION] score of 15 is the highest score possible indicating that the resident is cognitively intact and has capacity. During the observation of the lunchtime meal on 01/21/20 at 1:07 PM, Resident #[AGE] did not have a tray. Employee #126, Registered Nurse (RN) / Assistant Director of Nursing (ADON), was overheard stating to the staff on A-wing that all trays had been passed. During an interview on 01/21/20 at 1:08 PM, ADON #126 was asked if all residents A-wing had been served lunch. ADON #126 responded that all residents had been served, with the exception of one resident who was currently out of the facility. ADON #126 was then asked why Resident #[AGE] did not receive a tray during the initial meal delivery on the unit. ADON #126 stated Resident #[AGE] eats in the dining room. After surveyor intervention, ADON #126 went to Resident #[AGE]s room and asked Resident #[AGE] if she had eaten lunch, to which Resident #[AGE] responded that she had not received her lunch. On 01/21/20 at 1:11 PM, ADON #126 returned from getting Resident #[AGE]'s tray from the tray cart sitting in the dining room in Building 2. ADON #126 was going to serve Resident #[AGE] the tray that had been sitting in the dining room tray cart. A new tray was requested for Resident #[AGE], as well as for the Dietary Manager to come with a thermometer. A review of the Tray Delivery Schedule noted that lunch trays were scheduled to be delivered to the dining room in building 2 at 12:15 PM. On 01/21/20 at 1:17 PM, Employee #266, Shift Supervisor, tested Resident #[AGE]'s original tray. The following temperatures were obtained: turkey - 117 degrees, chopped broccoli - 118 degrees, baked sweet potato -144 degrees, and a carton of milk - 34.8 degrees. The dessert recipe called for the dish to be served at room temperature, so a temperature was not obtained for that item. When asked what temperature hot foods should be at the time a resident receives the item, Employee #266 stated that hot foods should be at least 120 degrees at the point of service, or time when a resident receives the food items. On 01/22/20 at 8:14 AM, the findings were discussed with the Administrator. No further information was provided prior to the end of the survey on 0[DATE] at 11:00 AM.",2020-09-01
1311,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,812,E,0,1,SW6S11,"Based on observation and staff interview, the facility failed to maintain its kitchen in a safe and sanitary manner when they failed to discard outdated bologna and cheese and failed to date a large tub of diced peaches. This deficient practice was found during a random opportunity for discovery and had the potential to affect more than an isolated number of residents. Facility census: 176. Findings included: a) Initial Kitchen Tour An initial tour of the facility's main kitchen began on 01/20/20 at 10:47 AM. At 10:51 AM in a reach-in cooler, a large square plastic container with bologna inside had a handwritten label with the following information: 1-10-20/1-17-20. Next to the first container, a second large square plastic container with cheese inside had a handwritten label with the following information: 01-3-20 1-15-20. At 10:53 AM, Dietary Employee (DE) #266 stated, That's a no-no, upon viewing the containers. DE #266 then removed the containers from the reach-in cooler, confirming that the bologna container should have been removed after 01/17/20 and that the cheese container should have been removed after [DATE]. At 10:56 AM, a large metal tub of cubed peaches in liquid in a walk-in cooler was observed to have no date. At 10:58 AM, DE #268 stated that the peaches should have been dated. At 10:59 AM, DE #268 was observed writing a date on the container of peaches. The above concerns were discussed with the facility's Administrator on 01/21/20 at 10:53 AM, and no further information was provided prior to exit.",2020-09-01
1312,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,842,D,0,1,SW6S11,"Based on medical record review and staff interview, the facility failed to ensure medical records were complete and accurate for one (1) of 35 residents reviewed during the long-term care survey process. Resident identifier: #7. Facility Census: 176. Findings included: a) #7 Review of Resident #7's medical records revealed a progress note written on [DATE] at 12:32 PM, which stated, X-ray to left foot reviewed by (name redacted), FNP (family nurse practitioner)- Acute bimalleolar fractures present. New orders: Non weight bearing until seen by ortho (orthopedic) to left ankle, Splint to be placed to left ankle by PT (physical therapy). PT aware. Vit (vitamin) D level on 10-3-19, Check pulses q (every) shift to left foot. Resident has capacity and is aware. The progress notes contained no explanation of the events leading to the necessity for the x-ray. A progress note written by the Nurse Practitioner on [DATE] at 11:21 PM and identified as a late entry note stated, (Name redacted) was seen today for routine follow up visit and it was reported that he had a fall and a follow up x-ray to the left ankle. An incident/accident report written on [DATE] at 5:00 AM stated, CNA (Certified Nursing Assistant} came to this nurse stating that resident had hurt his left ankle. Upon assessing resident, left ankle noted to be swollen. Resident unable to bear weight to left ankle. Resident stated that he was going back to hid (sic) bed after going to the bathroom and tripped and almost fell . He stated that he did not fall, but he did twist his ankle.Dr. (name redacted) notified, gave order for x-ray to left ankle. According to the incident/accident report, the document is not part of the Medical Record. During an interview on 01/22/20 at 10:30 AM, the Director of Nursing acknowledged Resident #7's progress notes did not contain an explanation of the incident which occurred on [DATE] and resulted in fractures of the resident's ankle. No further information was provided through the completion of the survey.",2020-09-01
1313,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,867,E,0,1,SW6S11,"Based on record review, policy review and staff interview the facility failed to ensure the Quality Assessment and Assurance (QA&A) committee corrected quality deficiencies it had knowledge of. The facility had a Complaint Survey from 10/28/19 through 10/31/19 during which time they were issued citations that included F558, F5[AGE], F656, F689, and F[AGE]4. The facility submitted a plan of correction and indicated they would have everything corrected by 01/06/20. An annual survey was conducted from 01/20/20 through 0[DATE] at which time the following tags were recited F558, F5[AGE], F656, F689, and F[AGE]4. Therefore the facility's QA&A Committee failed to correct identified deficient practices. This practice has the potential to effect all residents currently residing in the facility. Facility census: 176. Findings include: a) Cross reference deficiency cited at F 558 b) Cross reference deficiency cited at F 5[AGE] c) Cross reference deficiency cited at F 656 d) Cross reference deficiency cited at F 689 e) Cross reference deficiency cited at F [AGE]4 During an interview on 0[DATE] at 8:29 AM with the Administrator, the findings related to Quality Assurance were discussed with the Administrator. The Administrator stated that they are currently reviewing the action steps related to the repeat deficient practices. The Administrator discussed future ways that they would track and trend, educate, and / or discipline regarding areas that were a repeat deficient practice. No further information was provided prior to the end of the survey on 0[DATE] at 11:00 AM.",2020-09-01
1314,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2020-01-23,880,D,0,1,SW6S11,"Based on observation, staff interview the facility failed to ensure must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of two (2) residents reviewed for the care area of urinary catheter. Resident identifier: #6. Facility census: 176. Findings included: a) Resident #6 On 01/22/20 at 10:10 AM, indwelling urinary catheter care and pericare performed by Certified Nursing Assistant (CNA) #63 for Resident #6 was observed. CNA #63 wet two (2) washcloths using water from the resident's sink. A plastic washbasin with the resident's name on it was noted to be lying on the sink counter. CNA #63 placed the two wet washcloths directly on the resident's bedside table. She did not clean the table prior to placing the washcloths on it. CNA #63 used the washcloths from the bedside table, putting soap on them and using them to wipe the resident's periarea and catheter. The surface of the bedside table could contain infectious organisms that could be transferred to the resident during catheter care and pericare by the washcloths. On 01/22/20 at 10:20 AM, the Director of Staff Education was interviewed. She stated Nursing Assistants are taught to not place clean items directly onto residents' bedside tables without using a barrier. The Director of Staff Education stated in this situation, the Nursing Assistant should have used the resident's plastic basin to place the washcloths for catheter care and pericare. The facility's Director of Nursing was informed of the above findings on 01/22/20 at 10:34 AM, and no further information related to the deficient practice was provided by the end of the survey.",2020-09-01
1315,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2018-02-15,550,D,0,1,WI9G11,"Based on observation and staff interview, the facility failed to ensure each resident was treated in a dignified manner. The indwelling urinary catheter urine collection bag was uncovered for one (1) out of two (2) residents reviewed for the care area of urinary catheter. Resident identifier: #402. Facility census: 177. Findings include: a) #402 On 02/13/18 at 4:31 PM, Resident #402's indwelling urinary catheter urine collection bag was noted to be hanging on her bed without a covering. Nurse Aide (NA) #123 verified Resident #402's indwelling urinary catheter urine collection bag did not have a covering. NA #123 stated urine collection bags should be covered. She stated she would have a covering applied. During an interview on 02/13/18 at 4:42 PM, the Director of Nursing stated a covering had been applied to Resident #402's indwelling urinary catheter urine collection bag. On 02/14/18 at 3:12 PM, Resident #402's indwelling urinary catheter urine collection bag was noted to be covered with a dark blue covering.",2020-09-01
1316,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2018-02-15,585,D,0,1,WI9G11,"Based on resident interview, staff interview and a review of grievances the facility failed toe nurse one (1) of two (2) residents reviewed for the area of personal property had the right to file a grievances and receive prompt efforts to have the grievance resolved. In addition the facility did not ensure the resident was apprised of progress toward a resolution. Resident #142 had informed staff about missing clothing however, the staff had not documented these concerns or kept the resident apprised to details of a resolution to her concern. Resident identifier: #142. Facility census: 177. Findings include: a) Resident #142 During an interview, on 02/12/18 at 12:46 PM, Resident #142 said she had five (5) pair of missing pants. The resident said she had told staff but they had not done anything about it. On 02/14/18 at 12:06 PM, during an interview with Clinical Quality Consultant (CQC) #260, the CQC said she would talk with Assistant Administrator (AA)# 81 about the missing pants. CQC #260 later said AA #81 had no knowledge about the missing pants. During an interview with Resident #142 on 02/14/18 at 12:30 p.m. the resident said she did have five (5) pair of missing pants. She described them as blue, gray, black and two (2) pair of brown pants. She said she had hemmed them herself. Resident #142 said she had told everybody. Nurse Aide (NA) #34 was present during this interview and acknowledged that she had known the resident had missing pants. She told the resident she had looked in laundry for the pants. NA #34 said she told her supervising nurse about the missing pants but did not remember this nurse's name. On 02/14/18 at 1:00 PM the director of nursing asked the resident again about the missing pants. The resident's roommate had visitors at that time and the visitor confirmed the resident did have the pants and had worn them to therapy. The director of nursing completed a concern/grievance form on 02/14/18 regarding the missing pants.",2020-09-01
1317,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2018-02-15,600,D,1,1,WI9G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, record review and staff interview the facility failed to ensure the rights to be free from neglect, including prevention from falls. Resident identifier: #447. Census 177. Findings included: a) Resident # 447 During an interview on 02/12/18 11:28 AM, the resident said that she fell last week while two nurses were loading her on a lift to take her to the scales for a weight. She stated she was still having some soreness in her lower back from the fall. She was not sure of the date, but thought it was a couple of days ago. When the surveyor asked if they had done an x-ray or anything to make sure that nothing was broken, she said, no they had not. On 2/13/18 at 09:30 AM, the DON#204 was aked about the accident and if she could find the report. On 02/13/18 at 11:00 AM, the DON #204 stated that she could not find any report because they only found out about the incident on Monday when the surveyor was interviewing the resident, because a nurse aide had overheard Resident # 447 describe the accident and reported it to a charge nurse. On 02/14/18 at 08:06 AM, the DON #204 said that she had instructed a nurse to make the report, but that the nurse had forgotten to do so. Record review showed an x-ray was ordered later on Monday 02/12/18 at 12:00 PM after the initial interview. Results on the x-ray were negative per DON #204. DON #204 said that she and Nurse Practitioner #261 interviewed the resident and felt the resident was confused. Record review revealed the Physicians determination of capacity for Resident # 447 signed on 02/08/18 states that she demonstrates CAPACITY. During an interview on 02/14/18 at 08:20 AM with Resident # 447 and her spouse, when asked whether she could remember what day it was or if there was a TV program on that day that could help her remember, her spouse said he had it written it down in his pocket calendar. He showed the surveyor his calendar where he had written she fell on [DATE] at about 10:30 PM. He found out about it the next morning on 02/08/18 when his wife told him and made a note on his pocket calendar. Surveyor interviewed Resident # 447 more to ask if she could describe exactly what happen. Resident # 447 said that two nurses were weighing her on the scales beside of the pop machines. One nurse wanted something out of the pop machine and went to the machine. Then the other nurse turned to help the first nurse telling her to hold on to the bar and down she (the resident) went. The two nurses helped her back up. During an interview on 02/14/18 at 08:27 AM, to notify the DON of the findings, she was asked where the scales were. They were right beside the soda machine. Administrator #233 was at the soda machines and said that she did not believe that it happened because the resident said that two nurses weighed her when nurses do not do that the nurse aides do. With more discussing, she agreed that people do call all people wearing scrubs nurses. The care plan initially dated 02/07/18 stated the resident required assistance with activities of daily living related to impaired mobility with: T--ransfer status: Total lifting using small navy lift pad two person assist. Records indicate that her weight was done on 02/07/18 at 10:38 PM. No other weights were recorded.",2020-09-01
1318,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2018-02-15,609,D,1,1,WI9G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident and family interview, staff interview, and record review the facility failed to report an allegation violations related to neglect, immediately, or not later than two hours after the allegation was made. If the events that cause the allegation did not involve abuse or result in serious bodily injury, no later then twenty four hours. The report of all investigations to the administrator, including to the State Survey Agency, within five working days of the incident. Findings include: a) Resident # 447 Based on resident interview, record review and staff interview the facility failed to ensure the rights to be free from neglect, including prevention from falls. Resident identifier: #447. Census 177. Findings included: a) Resident # 447 During an interview on 02/12/18 11:28 AM, the resident said that she fell last week while two nurses were loading her on a lift to take her to the scales for a weight. She stated she was still having some soreness in her lower back from the fall. She was not sure of the date, but thought it was a couple of days ago. When the surveyor asked if they had done an x-ray or anything to make sure that nothing was broken, she said, no they had not. On 2/13/18 at 09:30 AM, the DON#204 was aked about the accident and if she could find the report. On 02/13/18 at 11:00 AM, the DON #204 stated that she could not find any report because they only found out about the incident on Monday when the surveyor was interviewing the resident, because a nurse aide had overheard Resident # 447 describe the accident and reported it to a charge nurse. On 02/14/18 at 08:06 AM, the DON #204 said that she had instructed a nurse to make the report, but that the nurse had forgotten to do so. Record review showed an x-ray was ordered later on Monday 02/12/18 at 12:00 PM after the initial interview. Results on the x-ray were negative per DON #204. DON #204 said that she and Nurse Practitioner #261 interviewed the resident and felt the resident was confused. Record review revealed the Physicians determination of capacity for Resident # 447 signed on 02/08/18 states that she demonstrates CAPACITY. During an interview on 02/14/18 at 08:20 AM with Resident # 447 and her spouse, when asked whether she could remember what day it was or if there was a TV program on that day that could help her remember, her spouse said he had it written it down in his pocket calendar. He showed the surveyor his calendar where he had written she fell on [DATE] at about 10:30 PM. He found out about it the next morning on 02/08/18 when his wife told him and made a note on his pocket calendar. Surveyor interviewed Resident # 447 more to ask if she could describe exactly what happen. Resident # 447 said that two nurses were weighing her on the scales beside of the pop machines. One nurse wanted something out of the pop machine and went to the machine. Then the other nurse turned to help the first nurse telling her to hold on to the bar and down she (the resident) went. The two nurses helped her back up. During an interview on 02/14/18 at 08:27 AM, to notify the DON of the findings, she was asked where the scales were. They were right beside the soda machine. Administrator #233 was at the soda machines and said that she did not believe that it happened because the resident said that two nurses weighed her when nurses do not do that the nurse aides do. With more discussing, she agreed that people do call all people wearing scrubs nurses. The care plan initially dated 02/07/18 stated the resident required assistance with activities of daily living related to impaired mobility with: --Transfer status: Total lifting using small navy lift pad two person assist. Records indicate that her weight was done on 02/07/18 at 10:38 PM. No other weights were recorded.",2020-09-01
1319,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2018-02-15,655,D,0,1,WI9G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that a summary of the baseline care plan was provided to the resident and the resident representative for one (1) out of six (6) baseline care plans reviewed. Resident identifier: #142. Facility census: 177. Findings included: a) Resident #142 Resident #142 was admitted to the facility on [DATE]. A baseline care plan was completed for Resident #142 on 01/04/18. However, the medical records did not contain documentation Resident #142 and her representative received a written summary of the baseline care plan. On 02/14/18 at 4:18 PM, Assistant Director of Nursing (ADON) #31 confirmed the medical records did not contain documentation that Resident #142 and her representative received a written summary of the baseline care plan. ADON stated Resident #142 was admitted on night shift, and the staff on night shift do not do many resident admissions.",2020-09-01
1320,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2018-02-15,656,D,0,1,WI9G11,"Based on medical record review and staff interview, the facility failed to implement the person-centered care plan to meet the goals, and address the resident's medical, physical and psychosocial needs. This was true for one (1) of four (4) resident care plans reviewed for the care area of accidents. The care plan for Resident #7 had addressed the potential for injury from falls, with an intervention to apply Dycem to the geri chair. Resident identifier: #7. Facility census: 177. Findings include a) Resident #7 A record review for Resident #7 on 02/13/18 the care plan addressed potential for falls with injury. Among the interventions, included Dycem to seat of geri chair. Dycem is a non-slip matting used to stabilize a surface. During an observation on 02/14/18 02:05 PM, it was discovered Resident #7 was in her geri chair and no Dycem had been applied to the seat of her geri chair. The non-slip matting was used to assist in preventing Resident #7 from sliding out of her geri chair. An interview with Employee #240,Licensed Practical Nurse (LPN) on 02/14/18 at 2:20 PM, verified the Dycem had not been applied to Resident #7's geri chair.",2020-09-01
1321,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2018-02-15,657,D,0,1,WI9G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure an accurate revision for one (1) out of 35 comprehensive care plans reviewed. Resident identifier: #113. Facility census: 177. Findings include: a) Resident #113 Resident #113 was receiving the antipsychotic medication [MEDICATION NAME] (aripiprazole) for hallucinations, visual aggression, and combativeness. On 02/08/18, Resident #113's [MEDICATION NAME] dosage was decreased from 2 milligrams (mg) one time a day to 1 mg at bedtime every other day. On 02/08/17, Resident #113's comprehensive care plan was revised to include the intervention to give [MEDICATION NAME] 1 mg every night. During an interview on 02/13/18 at 3:48 PM, the Director of Nursing (DON) reviewed Resident #113's comprehensive care plan containing the intervention to give [MEDICATION NAME] 1 mg every night. The DON also reviewed Resident #113's order for [MEDICATION NAME] 1 mg every other night. The DON had no further information regarding the matter.",2020-09-01
1322,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2018-02-15,684,E,0,1,WI9G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of nine (9) residents reviewed for unnecessary medications received medication according to physician's orders [REDACTED].#23. Facility census: 177. Findings included: a) Resident #23 Review of the resident's Medication Administration Record [REDACTED]. The order directed staff to obtain the resident's blood sugars (BS) before meals (breakfast, lunch and supper) and hold the insulin if the resident's BS sugar is less than 100. A second order, directed staff to inject 15 units of [MEDICATION NAME], subcutaneously after meals and hold if BS before meals is less than 100. At 10:30 aAM on 02/14/18, Registered Nurse (RN) #191 said he interrupted the order as check the BS before meals and administer the [MEDICATION NAME] after meals and hold if BS is less than 100. He said he did not obtain the BS after the meal to determine if the [MEDICATION NAME] is to be held. He said it was an unusual order and assumed the order was written differently for this resident because, she has bottomed out before. At 10:37 AM on 02/14/17, the nurse practitioner (NP) said she had written the order and that was how she wanted the [MEDICATION NAME] to be administered. The NP said the resident's blood sugars really fluctuate. The staff were calling her frequently about the resident so she wrote a new order and added the parameters. She said the order is unusual but works for this resident. The NP reviewed the February, (YEAR), MAR indicated [REDACTED] --On 02/02/18, the resident's noon BS was 80. The [MEDICATION NAME] was initialed as given by the nurse. --On 02/05/18, the resident's noon BS was 74. The [MEDICATION NAME] was initialed as given by the nurse. --On 02/08/18, the resident's BS was 80 at noon, the nurse administered the [MEDICATION NAME]. --On 02/08/18, the resident's BS was 86 before the evening meal. The [MEDICATION NAME] was initialed as given by the nurse. --On 02/09/18 the resident's BS was 97, before the evening meal. The nurse administered the [MEDICATION NAME]. The NP said it appeared some nurses were obtaining the BS after meals and basing the decision to give the [MEDICATION NAME] based on the BS reading obtained after the resident had consumed her meal. The January, (YEAR) MAR indicated [REDACTED]. --On 01/24/18, the resident's BS was 68 before the evening meal. The nurse administered the [MEDICATION NAME]. --On 01/29/18, the resident's BS was 82 before the evening meal. The nurse administered the [MEDICATION NAME]. From the time the order was written, 01/23/18 until the date of review, 02/14/18, the [MEDICATION NAME] was administered on seven (7) occasions when the [MEDICATION NAME] should have been held.",2020-09-01
1323,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2018-02-15,689,D,0,1,WI9G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record reviews the facility failed to ensure the residents environment remains as free from accidents for Resident # 447. Resident identifier: #447. FAciliy census: 177. Findings included: a) Resident # 447 During an interview on 02/12/18 11:28 AM, the resident said that she fell last week while two nurses were loading her on a lift to take her to the scales for a weight. She stated she was still having some soreness in her lower back from the fall. She was not sure of the date, but thought it was a couple of days ago. When the surveyor asked if they had done an x-ray or anything to make sure that nothing was broken, she said, no they had not. On 2/13/18 at 09:30 AM, the DON#204 was aked about the accident and if she could find the report. On 02/13/18 at 11:00 AM, the DON #204 stated that she could not find any report because they only found out about the incident on Monday when the surveyor was interviewing the resident, because a nurse aide had overheard Resident # 447 describe the accident and reported it to a charge nurse. On 02/14/18 at 08:06 AM, the DON #204 said that she had instructed a nurse to make the report, but that the nurse had forgotten to do so. Record review showed an x-ray was ordered later on Monday 02/12/18 at 12:00 PM after the initial interview. Results on the x-ray were negative per DON #204. DON #204 said that she and Nurse Practitioner #261 interviewed the resident and felt the resident was confused. Record review revealed the Physicians determination of capacity for Resident # 447 signed on 02/08/18 states that she demonstrates CAPACITY. During an interview on 02/14/18 at 08:20 AM with Resident # 447 and her spouse, when asked whether she could remember what day it was or if there was a TV program on that day that could help her remember, her spouse said he had it written it down in his pocket calendar. He showed the surveyor his calendar where he had written she fell on [DATE] at about 10:30 PM. He found out about it the next morning on 02/08/18 when his wife told him and made a note on his pocket calendar. Surveyor interviewed Resident # 447 more to ask if she could describe exactly what happen. Resident # 447 said that two nurses were weighing her on the scales beside of the pop machines. One nurse wanted something out of the pop machine and went to the machine. Then the other nurse turned to help the first nurse telling her to hold on to the bar and down she (the resident) went. The two nurses helped her back up. During an interview on 02/14/18 at 08:27 AM, to notify the DON of the findings, she was asked where the scales were. They were right beside the soda machine. Administrator #233 was at the soda machines and said that she did not believe that it happened because the resident said that two nurses weighed her when nurses do not do that the nurse aides do. With more discussing, she agreed that people do call all people wearing scrubs nurses. The care plan initially dated 02/07/18 stated the resident required assistance with activities of daily living related to impaired mobility with: --Transfer status: Total lifting using small navy lift pad two person assist. Records indicate that her weight was done on 02/07/18 at 10:38 PM. No other weights were recorded.",2020-09-01
1324,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2018-02-15,842,D,0,1,WI9G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a complete an accurate medical record for two (2) of thirty-five (35) residents whose records were reviewed during the long term care survey. Resident #39, who was receiving hospice services, had a physician's orders [REDACTED]. Resident #194's record was not completed indicating his discharge location. Resident identifiers: #39 and #194. Facility census: 177. Findings include: a) Resident #39 Medical record review on 02/14/18 at 8:30 AM, found a physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. --One, dated 08/26/15, noting the resident's prognosis was good. --The second order, dated 08/26/15, noted the resident's rehabilitation potential was good. Employee #196, a nurse, DCD (abbreviation unknown) said, I believe the doctor needs to update the orders, at 9:32 a.m. on 02/14/18. b) Resident #194 A review of Resident #194's medical record revealed a progress note, dated 11/14/17 at 9:54 AM, which stated, Therapeutic leave of absence with medications. This was the last progress note documented in the resident's medical record. An interview with Social Worker (SW #237) on 02/15/18 at 9:25 AM revealed SW #237 had no further information regarding Resident #194's discharge from the facility. She said she thought he had some family problems and that was why he left the facility. An interview with Business Office Manager (BOM) #54 on 02/15/18 at 9:30 AM revealed BOM #54 had a note in her activity report dated 11/20/17 which stated, (Resident #194) left facility on 11/14 LOA (leave of absence) for family emergency. There has been no contact with family regarding his return. LOA under Medicaid is a max of 6 day. Per (name), no need to keep LOA day in census, we can not bill for those days. Updating census to show discharge date of ,[DATE]. (Assistant Administrator #81) notified regarding this chance (change). During an interview, on 02/15/18 at 9:45 AM with Clinical Quality Consultant #260 the lack of documentation in the medical record regarding Resident #194's discharge was discussed. The activity report from BOM #54 was not part of the resident's medical record. It was confirmed that the medical record did not contain sufficient documentation to show the circumstances surrounding Resident #194's discharge.",2020-09-01
1325,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2018-02-15,880,D,0,1,WI9G11,"Based on observation and staff interview, the facility failed to maintain infection control practices to prevent the development and transmission of communicable diseases and infections. The indwelling urinary catheter tubing was observed to be lying on the floor for one (1) of two (2) residents reviewed for the care area of urinary catheter. Resident identifier: #402. Resident census: 177. Findings include: a) Resident #402 On 02/13/18 at 4:31 PM, Resident #402's indwelling urinary catheter urine collection bag was noted to be hanging off her bed with the tubing lying on the floor. Nurse Aide (NA) #123 verified Resident #402's indwelling urinary catheter tube was lying on the floor. NA #402 stated urinary catheter tubing should not lie on the floor. She stated she would have the tubing. During an interview on 02/13/18 at 4:42 PM, the Director of Nursing stated Resident #402's indwelling urinary catheter urine collection bag and tubing had been changed. On 02/14/18 at 3:12 PM, Resident #402's indwelling urinary catheter tubing was observed to no longer be lying on the floor.",2020-09-01
1326,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-07-03,580,D,1,0,X6R911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, and staff interview and review of the facility's policy, the facility failed to notify the physician when the nursing staff did not write the physician's orders [REDACTED]. Resident identifer: #4. Facility census: 181. Findings included: a) Resident #4 A review of the weekly wound evaluation found on 07/02/19 at 2:10 PM, Resident #4 had a Stage II pressure ulcer on her right posterior thigh measuring three (3) centimeters (CM) by three (3) CM with a depth of 0.1 CM. The nursing staff measured Resident #4's pressure ulcer the day after the resident was admitted , which was 05/21/19. A review of Resident #4's physician order [REDACTED].#4's right posterior thigh with in house wound care, pat dry, apply barrier cream ever shift and whenever needed (PRN). An interview was conducted on 07/02/19 at 2:34 PM, with Registered Nurse (RN) #240. This RN revealed Resident #4's pressure ulcer to her right posterior thigh was identified on admission. RN #240 said she had so many wound care orders to write that she had failed to write the wound care order the physician had given her for Resident #4's Stage II pressure ulcer to her right posterior thigh on 05/21/19, when she wrote all the rest of Resident #4's wound care orders. RN #240 confirmed that she did not realized the physician order [REDACTED]. RN #240 stated that, this is the reason why the physician order [REDACTED].#240 confirmed Resident #4 did not receive wound care for three (3) day. RN #240 was asked whether she had notified the physician once she identified the wound care order was not written and no wound care was provided to Resident #4's right posterior thigh pressure ulcer. RN #240 stated, No. A review of the facility's policy wound treatment guidelines finds the center will follow specific physician order [REDACTED].>",2020-09-01
1327,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-07-03,584,D,1,0,X6R911,"> Based on observation and staff interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The main dining room floor had one (1)piece of tile that was cracked with tile missing out of the center in which there was a hole that was uneven whenever anyone walked on this piece of tile. This had the potential to affect a limited number of residents. Facility census: 181. Findings included: a) Main dining room floor. Observation on 07/02/19 at 4:40 PM, found in the main dining room floor, one (1)piece of tile that is cracked with tile missing out of the center in which this made a hole that was uneven whenever anyone walked on this piece of tile. This tile lays in a high traffic area where the residents, family and the public walk on the floor of the main dinning room. Observation and interview with the Maintenance Director (MD)#23 on 07/02/19 at 4:45 PM, was asked, should this one (1)piece of tile that is cracked with tile missing out of the center in which this made a hole that is uneven whenever anyone walked on this piece of tile be fixed. The Director of Environmental Services (DES) said the concrete has settled and cracked the tile. The DES said the tile in whole dining room needs replaced.",2020-09-01
1328,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-07-03,585,D,1,0,X6R911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, family interview, and record review, the facility failed to identify and promptly address complaints/grievances to resolution and keep residents appropriately apprised of progress toward resolution. This was true when resident council notified the facility of complaints and grievances, discussed at the 2019 (MONTH) and (MONTH) resident council meetings, concerning nurse aides (NA) taking breaks at the same time leaving the units short staffed. The facility failed to provide re-education to all nurse aides (NA) as the facility designated as their corrective action regarding this on-going resident council grievance and concern. This was also true when the facility failed to address a grievance and allegation Resident (R#7)'s family member brought to the attention of a nurse concerning a NA allegedly treating R#7 disrespectfully and being verbally abusive toward the resident. This practice had the potential to affect more than a limited number of residents. Resident identifier: #7. Facility census: 181. Findings included: a) Resident council concerns On 07/01/19 at 1:35 PM, review of Resident Council meeting minutes dated 05/16/19 and 06/20/19, revealed an issue identified by residents concerning not having enough nurse aids (NA) on the floor to assist residents, due to NAs going on breaks together at the same time. In the (MONTH) minutes, attached was a 'Resident Council Concern' form with the corrective action listed Nursing assistance will be provided with re-education on taking breaks only during assigned times and to always report to the nurse when leaving their assigned area. An interview, on 07/03/19 at 12:21 PM, with the Director of Staff Education confirmed she was responsible for providing trainings, education, and re-education to staff. The Director of Staff Education verified she was aware of the residents' grievance concerning nurse aids leaving together on breaks and being short on staff during those times. When asked for the sign in sheet of the nurse aids that attended the re-education, the Director of Staff Education said she didn't have one. She explained she does not handle filling out complaint grievance forms, and re-education was not given to all nurse aids. The Director of Staff Education stated Residents complained, I don't know who, during a resident council meeting. We gathered the NAs at the nurse's desk and threatened disciplinary action. It was informal instruction given to some of the nurse aids, it was more like a pow wow, and it was taken care of and resolved. This surveyor asked if the issue was resolved, why did it show up again in June's resident council minutes. The Director of Staff Education did not reply. On 07/03/19 at 12:41 PM, an interview with the administrator revealed the process for grievances and concerns. The administrator said, If a resident reports a person or has a grievance it will be directed to the appropriate supervisor, and the supervisor will do a grievance form. When a concern form is generated it goes to the grievance official, and they do customer services. Of course, if it's reportable it goes to the proper agencies. The goal is to have it resolved in 5 days. During resident council it is reported to the activities director and additional forms are filled out and sent to the appropriate Department managers. When asked who filled out the resident council concern form dated 05/16/19, the administrator verified she had completed the form and had written the corrective action. When asked what her expectation of the corrective action was, the administrator verified that all nurse aids should have received the re-education and a sign in sheet confirming their participation should have been completed. b) Resident R#7 grievance and allegation of verbal abuse was not addressed On 07/03/19 at 1:25 PM, an interview with resident R#7 daughter revealed several issues and concerns regarding the resident. The daughter expressed she felt the resident needed more supervised time on the omni cycle due to the beneficial effects it has on her Mom. The daughter stated the weekend prior to the resident going into the hospital on [DATE], words were exchanged between herself and a restorative nurse aide. The daughter stated on 06/15/19, the restorative aide refused to get the resident on the Omni cycle, even though the daughter explained how much Mom loves this cycle and how important it was for her to have her time on the cycle. The daughter said, The restorative NA#1 got an attitude, and pointing at mom said, I tried before and she swatted at me, and I am not going to cater to her. She was rude and disrespectful to mom, she was abusive and refused to get my mom on the cycle. The daughter was asked where this exchange of words occurred, and she replied in the common area beside the nurse's station in front of the other residents, visitors, and staff. When asked if she had reported the incident to anyone the daughter replied, Staff was standing around, they saw and heard it. On Monday morning, when I came back to visit mom, though I did tell the Unit Nurse Manager (RN#59). The daughter said she has heard nothing else about it, as far as she knows they've done nothing about it. Interview with Unit Nurse Manager (RN#59), on 7/03/19 at 4:46 PM, revealed the daughter did report the incident as described to this surveyor to RN#59. RN#59 confirmed she did not fill out a grievance about the incident, nor did she identify any part of it as a reportable allegation. As far as RN#59 knew it had not been investigated or reported by her or any other staff.",2020-09-01
1329,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-07-03,607,D,1,0,X6R911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of reportable abuse/neglect allegations, grievance and complaint files, family interview, staff interview, and policy review, the facility failed to ensure they implemented their policy regarding identifying, investigating and reporting allegations of abuse/neglect. An allegation of verbal abuse was not identified, reported or thoroughly investigated. This was a random opportunity for discovery. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: R#7. Facility census: 181. Findings included: Review of records, on 06/24/19 at 2:15 PM, revealed Resident (R#7) is dependent with activities of daily living (ADL). R#7 is incontinent of bowel and bladder. Some pertinent [DIAGNOSES REDACTED]. On 07/03/19 at 1:25 PM, an interview with resident R#7 daughter (Healthcare Surrogate) revealed several issues and concerns regarding the resident. The daughter said she felt the resident needed more supervised time on the omni cycle due to the beneficial effects it has on her Mom. The daughter stated the weekend prior to the resident going into the hospital on [DATE], words were exchanged between herself and restorative nurse aide (NA#1). The daughter stated on 06/15/19, the restorative aide refused to get the resident on the Omni cycle, even though the daughter explained how much Mom loves this cycle and how important it was for her to have her time on the cycle. The daughter said, The restorative NA#1 got an attitude, and pointing at mom said, I tried before and she swatted at me, and I am not going to cater to her. She was rude and disrespectful to mom, she was abusive and refused to get my mom on the cycle. The daughter was asked where this exchange of words occurred, and she replied in the common area beside the nurse's station in front of the other residents, visitors, and staff. When asked if she had reported the incident to anyone the daughter replied, Staff was standing around, they saw and heard it. On Monday morning (06/17/19), when I came back to visit mom, though I did tell the Unit Nurse Manager (RN#59). The daughter said she has heard nothing else about it, as far as she knows they've done nothing about it. Interview with Unit Nurse Manager (RN#59), on 7/03/19 at 4:46 PM, revealed the daughter did report the incident as described to this surveyor to RN#59. RN#59 confirmed she did not fill out a grievance about the incident, nor did she identify any part of the incident as a reportable allegation. As far as RN#59 knew it had not been investigated or reported by her or any other staff. Review of the facilities 'Abuse, Neglect and Exploitation' policy, implemented on 11/27/17 and last revised 02/01/19, revealed the definition for verbal abuse is as follows: Verbal abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Under Section IV, 'Identification of Abuse, Neglect and Exploitation,' some listed factors indicating possible abuse included resident, staff or family report of abuse and verbal abuse of a resident overheard. Under Section V, 'Investigation of Alleged Abuse, Neglect and Exploitation, revealed When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur an investigation is immediately warranted. Under Section VII, 'Reporting response of Abuse, Neglect and Exploitation, revealed to immediately report all alleged violations to the CEO/administrator . and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames.",2020-09-01
1330,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-07-03,609,D,1,0,X6R911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of reportable abuse/neglect allegations, grievance and complaint files, family interview, staff interview, and policy review, the facility failed to report to the state agency allegations of verbal abuse. This was a random opportunity for discovery. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: R#7. Facility Census: 181. Findings included: Review of records, on 06/24/19 at 2:15 PM, revealed Resident (R#7) is dependent with activities of daily living (ADL). R#7 is incontinent of bowel and bladder. Some pertinent [DIAGNOSES REDACTED]. On 07/03/19 at 1:25 PM, an interview with resident R#7 daughter (Healthcare Surrogate) revealed several issues and concerns regarding the resident. The daughter said she felt the resident needed more supervised time on the omni cycle due to the beneficial effects it has on her Mom. The daughter stated the weekend prior to the resident going into the hospital on [DATE], words were exchanged between herself and restorative nurse aide (NA#1). The daughter stated on 06/15/19, the restorative aide refused to get the resident on the Omni cycle, even though the daughter explained how much Mom loves this cycle and how important it was for her to have her time on the cycle. The daughter said, The restorative NA#1 got an attitude, and pointing at mom said, I tried before and she swatted at me, and I am not going to cater to her. She was rude and disrespectful to mom, she was abusive and refused to get my mom on the cycle. The daughter was asked where this exchange of words occurred, and she replied in the common area beside the nurse's station in front of the other residents, visitors, and staff. When asked if she had reported the incident to anyone the daughter replied, Staff was standing around, they saw and heard it. On Monday morning (06/17/19), when I came back to visit mom, though I did tell the Unit Nurse Manager (RN#59). The daughter said she has heard nothing else about it, as far as she knows they've done nothing about it. Interview with Unit Nurse Manager (RN#59), on 7/03/19 at 4:46 PM, revealed the daughter did report the incident as described to this surveyor to RN#59. RN#59 confirmed she did not fill out a grievance about the incident, nor did she identify any part of the incident as a reportable allegation. As far as RN#59 knew it had not been investigated or reported by her or any other staff. Review of the facilities 'Abuse, Neglect and Exploitation' policy, implemented on 11/27/17 and last revised 02/01/19, revealed the definition for verbal abuse is as follows: Verbal abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Under Section IV, 'Identification of Abuse, Neglect and Exploitation,' some listed factors indicating possible abuse included resident, staff or family report of abuse and verbal abuse of a resident overheard. Under Section V, 'Investigation of Alleged Abuse, Neglect and Exploitation, revealed When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur an investigation is immediately warranted. Under Section VII, 'Reporting response of Abuse, Neglect and Exploitation, revealed to immediately report all alleged violations to the CEO/administrator . and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames.",2020-09-01
1331,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-07-03,610,D,1,0,X6R911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of reportable abuse/neglect allegations, grievance and complaint files, family interview, staff interview, and policy review, the facility failed to identify, thoroughly investigate, or report an allegation of verbal abuse. This was a random opportunity for discovery. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: R#7. Facility census: 181. Findings included: Review of records, on 06/24/19 at 2:15 PM, revealed Resident (R#7) is dependent with activities of daily living (ADL). R#7 is incontinent of bowel and bladder. Some pertinent [DIAGNOSES REDACTED]. On 07/03/19 at 1:25 PM, an interview with resident R#7 daughter (Healthcare Surrogate) revealed several issues and concerns regarding the resident. The daughter said she felt the resident needed more supervised time on the omni cycle due to the beneficial effects it has on her Mom. The daughter stated the weekend prior to the resident going into the hospital on [DATE], words were exchanged between herself and restorative nurse aide (NA#1). The daughter stated on 06/15/19, the restorative aide refused to get the resident on the Omni cycle, even though the daughter explained how much Mom loves this cycle and how important it was for her to have her time on the cycle. The daughter said, The restorative NA#1 got an attitude, and pointing at mom said, I tried before and she swatted at me, and I am not going to cater to her. She was rude and disrespectful to mom, she was abusive and refused to get my mom on the cycle. The daughter was asked where this exchange of words occurred, and she replied in the common area beside the nurse's station in front of the other residents, visitors, and staff. When asked if she had reported the incident to anyone the daughter replied, Staff was standing around, they saw and heard it. On Monday morning (06/17/19), when I came back to visit mom, though I did tell the Unit Nurse Manager (RN#59). The daughter said she has heard nothing else about it, as far as she knows they've done nothing about it. Interview with Unit Nurse Manager (RN#59), on 7/03/19 at 4:46 PM, revealed the daughter did report the incident as described to this surveyor to RN#59. RN#59 confirmed she did not fill out a grievance about the incident, nor did she identify any part of the incident as a reportable allegation. As far as RN#59 knew it had not been investigated or reported by her or any other staff. Review of the facilities 'Abuse, Neglect and Exploitation' policy, implemented on 11/27/17 and last revised 02/01/19, revealed the definition for verbal abuse is as follows: Verbal abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Under Section IV, 'Identification of Abuse, Neglect and Exploitation,' some listed factors indicating possible abuse included resident, staff or family report of abuse and verbal abuse of a resident overheard. Under Section V, 'Investigation of Alleged Abuse, Neglect and Exploitation, revealed When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur an investigation is immediately warranted. Under Section VII, 'Reporting response of Abuse, Neglect and Exploitation, revealed to immediately report all alleged violations to the CEO/administrator . and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames.",2020-09-01
1332,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-07-03,684,D,1,0,X6R911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and policy review, the facility fails to follow a physician order [REDACTED].#4. Facility census: 181. Findings included: a) Resident #4 A review of the weekly wound evaluation found on 07/02/19 at 2:10 PM, Resident #4 had a Stage II pressure ulcer on her right posterior thigh measuring three (3) centimeters (CM) by three (3) CM with a depth of 0.1 CM. The nursing staff measured Resident #4's pressure ulcer the day after the resident was admitted , which was 05/21/19. A review of Resident #4's physician order [REDACTED].#4's right posterior thigh with in house wound care, pat dry, apply barrier cream ever shift and whenever needed (PRN). An interview was conducted on 07/02/19 at 2:34 PM, with Registered Nurse (RN) #240. This RN revealed Resident #4's pressure ulcer to her right posterior thigh was identified on admission. RN #240 said she had so many wound care orders to write that she had failed to write the wound care order the physician had given her for Resident #4's Stage II pressure ulcer to her right posterior thigh on 05/21/19, when she wrote all the rest of Resident #4's wound care orders. RN #240 confirmed that she did not realized the physician order [REDACTED]. RN #240 stated that, this is the reason why the physician order [REDACTED].#240 confirmed Resident #4 did not receive wound care for three (3) day. RN #240 was asked whether she had notified the physician once she identified the wound care order was not written and no wound care was provided to Resident #4's right posterior thigh pressure ulcer. RN #240 stated, No. A review of the facility's policy wound treatment guidelines finds the center will follow specific physician order [REDACTED].>",2020-09-01
1333,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-07-03,686,D,1,0,X6R911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and policy review, the facility fails to timely provide the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (1) of five (5) residents reviewed for pressure ulcer care. Resident identifer: #4. Facility census: 181. Findings included: a) Resident #4 A review of the weekly wound evaluation found on 07/02/19 at 2:10 PM, Resident #4 had a Stage II pressure ulcer on her right posterior thigh measuring three (3) centimeters (CM) by three (3) CM with a depth of 0.1 CM. The nursing staff measured Resident #4's pressure ulcer the day after the resident was admitted , which was 05/21/19. A review of Resident #4's physician order [REDACTED].#4's right posterior thigh with in house wound care, pat dry, apply barrier cream ever shift and whenever needed (PRN). An interview was conducted on 07/02/19 at 2:34 PM, with Registered Nurse (RN) #240. This RN revealed Resident #4's pressure ulcer to her right posterior thigh was identified on admission. RN #240 said she had so many wound care orders to write that she had failed to write the wound care order the physician had given her for Resident #4's Stage II pressure ulcer to her right posterior thigh on 05/21/19, when she wrote all the rest of Resident #4's wound care orders. RN #240 confirmed that she did not realized the physician order [REDACTED]. RN #240 stated that, this is the reason why the physician order [REDACTED].#240 confirmed Resident #4 did not receive wound care for three (3) day. RN #240 was asked whether she had notified the physician once she identified the wound care order was not written and no wound care was provided to Resident #4's right posterior thigh pressure ulcer. RN #240 stated, No. A review of the facility's policy wound treatment guidelines finds the center will follow specific physician order [REDACTED].>",2020-09-01
1334,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-07-03,689,D,1,0,X6R911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, list of wound care supplies, and policy review, the facility failed to ensure a resident environment remains as free of accident hazards as is possible, over which the facility had control concerning an unlocked wound cart out of an authorized personnel eye sight and loose hand rails down a corridor. This was a random opportunity for discovery. This had the potential to affect a minimum number of resident. Facility census: 181. Findings included: a) Wound cart on D Hallway Observation on 07/03/19 at 10:55 AM, found a wound cart in the middle of the D hallway on the left hand side, unlocked, with the pull out doors of the wound cart facing the hallway. There were no one within eye sight of the wound cart. Registered Nurse (RN) #15 came out of a closed resident's room on the D hallway. When RN #15 was asked why the wound cart was left unlock and out of her eye signt. RN#15 stated, that another nurse had unlocked her wound cart for her due to they all have the same key and that she did not have a key to lock and unlock the wound cart, so she had to leave the wound cart unlocked. The inside the wound cart there were the following items: -- Sani cloth bleach wipes. -- Marathon - liquid skin protectant. --Triple antibiotic ointment- used as a first aid antibiotic to prevent infections in minor cuts, scrapes, [MEDICAL CONDITION] your skin. -- Normal saline bullets, necessary in removing dirt, debris and tissue from the area. --Staple removal kit (2) -- Suture remover. -- Alchol pads. -- [MEDICATION NAME] - is used as a skin protectant. -- Sure prep wipes - Fast-drying skin protectant is vapor permeable and delivers protection from friction and incontinence. Transparent barrier may be used on periwound, [MEDICATION NAME] or areas that come in contact with bodily fluids. -- [MEDICATION NAME] - This medication is used to prevent minor skin infections caused by small cuts, scrapes, or burns. [MEDICATION NAME] works by stopping the growth of certain bacteria. It belongs to a class of drugs known as antibiotics. This antibiotic only prevents bacterial infections. -- [MEDICATION NAME] one (1) % cream, silver Sulfadlazine cream is used to treat(e.g., insect bites, poison oak/ivy, [MEDICAL CONDITIONS], allergies [REDACTED]. -- Plastic bags. -- [MEDICATION NAME]- is a versatile multi-purpose barrier ointment to protect and heal inflamed and damaged skin. -- Anti-fungal powder - used to treat yeast infections. -- Anti-fungal cream - used to treat yeast infections. -- Anti- fungal powder, used to treat yeast infections. -- [MEDICATION NAME] 0.1 % cream - used to treat skin redness, burning, itching, irritation, excessive dryness, peeling. -- Dankins solution - used to prevent and treat skin and tissue infections that could result from cuts, scrapes and pressure sores. It is made from bleach that has been diluted and treated to decrease irritation. -- Wound cleanser- used to cleanse wounds. -- Acquaphor tubs- used is a topical ointment used (for the skin) [MEDICATION NAME] are used to treat or prevent dry skin. -- The wound cart had dressings supplies to place over the wound bed and pack into the wound bed, kling wraps, wound vac supplies in which has sponge material. In an interview on 07/03/19 at 11:00 AM, with RN #54, it was revealed the facility had four (4) carts, and there were four (4) different keys, so they decided about a week and half to change out the locks so they would all have the same keys. They have seven (7) staff they required to have keys for these wound carts and they only had four (4) out of the seven (7) keys available. RN #54 stated that, three (3) of the nursing staff are still waiting for their keys to be made. RN #54 verified that if you are doing wound care, and do not have a key to open and lock the wound cart, then another nurse who has a keys has to open your cart and you have to leave the cart open, you cannot lock the cart or you cannot get back into the wound cart to obtain your wound care supplies to perform wound care to your residents. There is 13 resident who can wander anywhere throughout the facility and the wound cart open facing the hallway made it accessible to resident in which it had the potential to result in injury or illness. The Administrator on 07/03/19 at 11:40 AM, provided a policy on medication storage. The Administrator said the facility's staff should always lock their medication/wound care carts at all times when they will be out of eye sight of the cart. The facility's medication storage policy revealed their medication supplies are to be locked or attended by persons with authorized access. b) Handrail on the corridor of Hallway [NAME] Observation on 07/03/19 at 3:30 PM, found the corridor handrail on the G hallway on the right hand side had two (2) handrails one (1) one each on both sides of a the soiled utility room turn from side to side. The handrail was loose. Nurse Aide (NA) #203, was in the hallway. The NA observed the handrails turn from side to side. The NA commented the resident reach up and grab these handrails and this could cause them to fall. The NA was asked how long had the handrails in the corridor been loose. NA #203 stated the hand rails have been loose for a week or so. The NA mentioned that she thought someone had turned this in. In an interview and observation on 07/03/19 at 3:40 PM, with the Maintenance Director (MD) #23, he verified the handrails were loose and required another screw on the bottom of the handrail to make the handrail more steady. He said he would fix the handrails immediately.",2020-09-01
1335,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-07-03,880,D,1,0,X6R911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interviews, and policy review, the facility failed to implement infection control practices and processes designed to prevent the transmission of disease, infection, and/or cross contamination concerning proper hand hygiene during wound care. This had the potential to affect one (1) of five (5) residents reviewed for pressure ulcer care. Resident identifers: #5 and #6. Facility census: 181. Findings included: a) Resident #5 A review of Resident #5's physician orders [REDACTED]. The wound is cleansed with in house wound cleanser, pat dry, apply [MEDICATION NAME], Acqual AG and bordered dressing every three (3) days and as needed. The resident's has a status [REDACTED]. Observation of Resident #5's wound care to her coccyx, and right knee was conducted on 07/02/19 at 10:00 AM. RN #54 went and washed his hands, then donned three(3) pair of gloves. RN #54 had prepped the over -the -bed table for Resident #5's wound care supplies. RN #240 assisted RN #54 to turn Resident #5 over onto her right side. RN #54 had touched Resident #5's back while turning her over. RN #54 then removed Resident #5's dressing, removed a pair of the gloves, sprayed the in house wound cleanser onto four (4) by four (4)gauge, cleansed Resident #5's coccyx area and applied a bordered dressing. RN #54 removed his gloves. RN #54 picked up the in house wound cleanser and sprayed the wound cleanser onto a four (4) by four (4), cleansed Resident #5's right knee, sprayed the liquid skin barrier onto the right knee surgical wound. RN #54 waved his hands over Resident #5's right knee surgical incision, then he removed his gloves. RN #54 was asked should you have performed wound care to Resident #5's surgical incision before performing pressure ulcer care to her coccyx. RN #54 acknowledged that he should have performed wound care to the resident's surgical site first, then performed wound care to Resident #5's coccyx. RN #54 was informed that he did not perform hand hygiene between touching the resident's back, removing the dressing, cleansing the wound, reapplying the dressing and then performing wound care to a surgical area. The RN verified that if he would of not donned so many pair of gloves, because he would of washed his hands. The RN acknowledged that this practice can cause infections that would cross contaminate one (1) wound to another wound. b) Resident #6 A review of Resident #56s physician orders [REDACTED]. The wound is cleansed with in house wound cleanser, pat dry, apply Calcium Alginate and a bordered dressing daily and whenever needed (PRN). Observation of Registered Nurse (RN) #240 perform wound care to Resident #6 on 07/02/19 at 4:00 PM, found the RN #54 had prepped the over -the -bed table for Resident #6's wound care supplies. RN #240 washed her hands, donned a pair of gloves. RN #54 assisted RN #240 to turned Resident #6 over to her right side. RN #240 removed the boarder gauze, and removed the Calcium Alginate packing from inside of the open wound, removed her gloves, donned another pair of gloves and then cleansed the wound with the in house wound cleanser, pat the sacrum area dry, introduced the calcium alginate into the inside of the wound bed and then applied a bordered dressing overtop of the wound. RN #240 removed her gloves. RN was asked how do you thing you did. The RN said I think I changed my gloves too many times. RN #240 was asked should you have washed your hands from removing the existing dressing, cleansing the wound and reapplying the packing and boarder dressing. The RN acknowledged that she did not wash her hands as she should have following removing the soiled Calcium Alginate dressing, cleansing the wound and reapplying the boarder dressing. A review of the facility's policy on clean dressing change on 07/19 finds the staff should washed hands and put on clean gloves prior to starting the wound care, following removing the existing dressing, cleansing the wound, and placing a new dressing onto the wound.",2020-09-01
1336,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-07-03,924,D,1,0,X6R911,"> Based on observations, staff interviews, the facility failed to ensure the corridors had firmly secured handrails on each side. The corridor handrails on the G hallway were lose. This was a random opportunity for discovery. Facility census: 181. Findings included: a) Hand rail on the corridor of Hallway [NAME] Observation on 07/03/19 at 3:30 PM, found the corridor handrail on the G hallway on the right hand side had two (2) handrails one (1) one each on both sides of a the soiled utility room turn from side to side. The handrail was loose. Nurse Aide (NA) #203, was in the hallway. The NA observed the handrails turn from side to side. The NA commented the resident reach up and grab these handrails and this could cause them to fall. The NA was asked how long had the handrails in the corridor been loose. NA #203 stated the hand rails have been loose for a week or so. The NA mentioned that she thought someone had turned this in. In an interview and observation on 07/03/19 at 3:40 PM, with the Maintenance Director (MD) #23, he verified the handrails were loose and required another screw on the bottom of the handrail to make the handrail more steady. He said he would fix the handrails immediately.",2020-09-01
1337,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-10-31,550,D,1,0,OVRC11,"> Based on observation and staff interview, the facility failed to maintain resident dignity during dining. Resident #9 was served breakfast with her brief exposed. In addition, her night gown was drooping exposing her upper body. This was a random opportunity for discovery. Resident identifier: #9. Facility census: 191. Findings included: a) Resident #9 On 10/31/19 at 8:55 AM, nursing assistant (NA) #63, delivered the breakfast tray to the resident in her room. NA #63 placed the resident's tray on her over-the-bed table and placed the resident in a sitting position. NA #63 left the resident room to continue serving trays. Resident #9's hospital gown was untied around her neck and the top of the gown was hanging below her neck exposing her white undergarment and her chest. Resident #9's legs were uncovered. An incontinence brief could be seen hanging between her legs, below the hem of the hospital gown, approximately mid-calf. Both could be seen from the hallway. At 10/31/19 at 9:03 AM, the resident's brief and uncovered upper portion of her body was still visible from the hallway and entryway to the resident's room. NA #63 continued to pass breakfast trays and did not return to adjust the resident's clothing and incontinence brief. On 10/31/19 at 9:05 AM, RN #77, Register Nurse (RN), was in the hallway at her med cart. RN #77 entered the residents room to give morning medications. RN #77 did attempt to tie the hospital gown and adjust it so that Resident #9's body was covered; however, RN #77 did not adjust the brief. On 10/31/19 at 9:06 AM, RN #77, confirmed the brief had a foul, strong urine odor and was visible from the hallways. RN #77 stated that she would assist the resident and take care of the incontinence brief. On 10/31/19 at 9:14 AM, the surveyor spoke with the Administrator regarding the findings and no further information was provided before the close of the survey on 10/31/19 at 3:00 PM.",2020-09-01
1338,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-10-31,551,D,1,0,OVRC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure the person making medical decisions for Resident #159 had the legal authority to act in the resident's behalf. This was true for one (1) of two (2) residents reviewed for advance directives. Resident identifier: #159. Facility census: 191. Findings include: a) Resident #159 Record review revealed Resident #159 was admitted to the facility on [DATE]. The resident had capacity to make medical decisions upon admission. The medical record contained a copy of a combined Medical Power of Attorney (MPOA) and Living Will created by the resident on 01/17/18. This document was signed by the resident and completed prior to admission. On 08/19/19 the facility physician determined the resident lacked capacity to make medical decisions. On 08/29/19, a physician's orders [REDACTED]. In addition, the individual who completed the POST form was not appointment by any physician or court to make medical decisions for this resident. The POST form directed the resident receive comfort measures, no feeding tube, no IV (intravenous) fluids for a trial period of no longer than 72 hours and a do not resuscitate order. At 1:45 PM on 10/30/19, the Social Worker (SW) #169 confirmed the individual who completed the POST form was not the resident's responsible party. At 10:49 AM on 10/31/19, the administrator said the social worker had informed her of the problems with the Resident's POST form. At the close of the survey on 10/31/19 at 3:00 PM, no further information was provided.",2020-09-01
1339,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-10-31,558,E,1,0,OVRC11,"> Based on observation and staff interview, the facility failed to ensure a call light was accessible and within reach for three (3) residents. This was a random opportunity for discovery. Resident identifiers: #2, #9, and #46. Facility census: 191. Findings include: a) Resident #2 On 10/28/19 at 9:37 AM, Resident #2's call light was observed to be clipped to the connector that goes into the wall. This connector and outlet is located behind the resident's bed and is approximately 20 inches away from the head of the bed out of the resident's reach. On 10/28/19 at 9:38 AM, Employee # 172, Activity Director, was called into room by the surveyor. Employee #172 confirmed that the resident's call light was not in reach of resident and was clipped to the cord plug located in the call light outlet / power [NAME] that was going into the wall behind the resident's bed. Employee #172 unclipped the call light from the cord near the cord plug-in as well as placed the call light close to the resident. b) Resident #9 On 10/28/19 at 9:40 AM, Resident #9's call light was observed on the floor under the bed, looped around the wheel of the bed. Employee #71, nursing assistant (NA), crawled on the floor and underneath the resident's bed. NA #71 pulled the call light from underneath the bed and placed in reach of the resident. c) Resident #46 On 10/28/19 at 9:41 AM, Resident #46's call light was located at the foot of her bed, beside the wall. The resident's bed was placed with one side against wall. Resident #46 was sitting in her wheelchair. Resident #46 was asked if she had her call light. Her responses was that she did not know where it was. Once the call light was identified at the foot of her bed and located against the wall, the resident was unable to reach call light. On 10/28/19 at 9:43 AM, Employee #225, Registered Nurse (RN), was observed in the hallway. RN #225 was asked to if she could come into Resident #46's room. RN #225 stated that she was a wound nurse, and this was not her patient. RN #225 did enter the resident's room and confirmed the call light was not within resident's reach. d) On 10/28/19 at 12:43 PM the findings for Residents #2, 9, and 46 were discussed with the Administrator. No additional information was provided prior to the close of the survey on 10/31/19 at 3:00 PM.",2020-09-01
1340,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-10-31,584,E,1,0,OVRC11,"> Based on observation, resident interview and staff interview the facility failed to ensure the resident environment was not kept clean and homelike. The shower room on the B- Hall and C - Hall were not kept clean. The following residents had the potential to be showered in the B- Hall and C- Hall shower room on 10/31/19: #2, #185, #48, #76, #135, #152, #119, #154, #178, #121, #66, #11, #10, #157, #30, #82, and #128. Facility census: 191. Findings included: a) During the resident council meeting on 10/30/19 at 1:00 p.m. multiple residents complained about the shower rooms in Building 2 being filthy. The further elaborated by stating, they leave dirty wash cloths and clothes on the floor and sometimes there is poop in the floor when you go in to get a shower. b) Observations of the B- hall and C- Hall shower rooms beginning at 10: 53 a.m. on 10/31/19 with Licensed Practical Nurse (LPN) #45 found a used wipe in the floor of the C-hall shower with a brown substance on it. LPN #45 stated that should not be in the floor. She put on a glove and picked it up and placed it in the trash can. The B- Hall shower rooms had multiple soiled wash cloths in the floor and draped over the grab bar. Also in the floor was a soiled hospital gown. LPN #45 stated the shower room needed to be cleaned up. She indicated after every resident shower the Nurse Aide (NA) should pick up all soiled linen and place it in the soiled linen cart. She agreed this had not been done.",2020-09-01
1341,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-10-31,610,D,1,0,OVRC11,"> Based on record review and staff interview the facility failed to ensure all allegations of abuse and/or neglect were thoroughly investigated. This was true for an allegation made by Resident #199. All staff members who had the potential to be alleged perpetrators did not provide a witness statement. This was true for one (1) of 4 (four) reportable incidents involving neglect. Resident identifier: #199. Facility census: 191. Findings included: a) Resident #199 A review of the reportable incidents found an incident dated 07/11/19. This reportable allegation was made by Resident #199. A review of the facility's Investigation Summary found the following written by Social Worker (SW) #151, under the section titled, Summary of Investigation: On 07/11/19, Pt. (patient) reported to evening shift RN (Registered Nurse) Manager, (First and Last Name of Registered Nurse #71), he had been spoken too in a harsh manner, handled roughly and a delay in call light response time. This was reported around 6:00 p.m. and that it had happened earlier in the day. Witness statements indicate staff checked on Pt. Pt. noted to have told CDM (Certified Dietary Manager) he was not staying in the facility and noted in the SS (Social Service) noted to be confused with some lethargy that day. It could not be determined Pt was handled roughly, that CNAs were rude or that there was a delay in call light response time. Further review of the investigation found SW #151 obtained statement from NA #16, NA #66, and NA #258. NA #16's statement read as follows: I (first and last name of NA #16) went into the room of (First and Last Name of Resident #199) with (First and Last Name of NA #258) to check his brief and see if he as Dry and he was, then we pulled him up in bed and got him another blanket because he was cold. NA #258's statement read as follows: I (First and Last Name of #258) went in (Resident #199's room number) room with (First and Last name of NA #16) to check resident to see if he needed changed. He was dry so we pulled him up in bed and I got him an extra blanket and exited the room. NA #66's statement read as follows: I am not assigned to (Room Number of Resident #199) Mr. (First and Last Name of Resident #199) I have not stepped into his room this shift I have not had any contact with Mr. (Last Name of Resident #199). All three (3) statements were obtained on 07/11/19. A review of the assignment sheets for Resident #199's room for 07/11/19 found NA # 44 was assigned to Resident #199 during the day shift on 07/11/19. There was no statement obtained from NA #44 about when or what type of care she provided for Resident #199. NA #16, #66 and #258 all three (3) worked evening shift and had only been at the facility for three (3) hours when Resident #199 voiced his complaint to RN #71 and stated it had happened earlier in the day. An interview with the Nursing Home Administrator (NHA) on 10/30/19 at 4:21 p.m. confirmed no statement was obtained from Na #44. The NHA indicated SW #151 was not available to ask why so she could not answer as to why NA #44 did not provide a witness statement.",2020-09-01
1342,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-10-31,656,D,1,0,OVRC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and record review, the facility failed to implement the care plan for one (1) of six (6) residents reviewed for falls. Resident identifier: #88. Facility census: 191. Findings included: a) Resident #88 A review of Resident #88's medical record revealed several falls: - 8/19/2019 at 8:45 PM - nurse's note revealed the resident had an unwitnessed fall. Resident was up walking around. - 9/09/2019 at 2:00 PM - fall note revealed the resident had an unwitnessed fall. Resident was ambulating by herself getting into her closet - 9/25/2019 at 7:00 PM - fall note revealed the resident had a witnessed fall. The resident was ambulating without assistance Review of Residents #88's care plan found a focus/problem: Risk for falls and potential for injuries from falls r/t (related to) impaired mobility, muscle weakness, incontinence, cognitive impairment, SOB (shortness of breath), hx (history) falls, [MEDICAL CONDITION] drug use, poor safety awareness, recent left [MEDICAL CONDITION]. The goal associated with this problem: Resident will have no major injury from falls, such as fractures, head injury, or dislocations, through next review period. Interventions included: - Encourage resident to use a reacher when trying to get objects out of their reach. - Place bed in highest position while resident is out of bed to prevent resident from trying to get into bed without assistance. On 10/28/19 at 11:43 AM, observation of Resident #88's room revealed Resident #88's bed was not in the highest position. The resident was not in the room. On 10/28/19 at 11:47 AM, Nursing Assistant (NA) #105 accompanied the surveyor into the resident's room. NA #105 stated that the resident's bed was not in the highest position, and demonstrated by adjusting the bed to the highest position. NA #105 stated that she was unaware that Resident #88 was care planned to have her bed in the highest position when the resident was not in bed. NA #105 was asked if she was aware of the location of Resident #88's reacher. NA #105 looked in the resident's room, drawers, closet, and bathroom and could not locate the resident's reacher. On 10/28/19 at 11:50 AM, Resident #88 was observed eating lunch in the dining room. Resident #88 did not have the reacher in her chair, under her chair, nor on her person. Employee #164, restorative aid, confirmed that Resident #88 did not have her reacher. On 10/28/19 at 11:52 AM, Employee #114, Licensed Practical Nurse (LPN), was asked if Resident #88 attempts to climb into her bed without assistance. LPN #114 stated that Resident #88 does climb in bed when she wants. LPN #114 was asked about placing the bed in the highest position. LPN #114 stated that that bed is never placed in the highest position. On 10/28/19 at 11:59 PM, Employee #210, Minimum Data Set (MDS) Registered Nurse (RN), reviewed the care plan. RN #210 confirmed that the intervention of the bed in highest position has been on the care plan since 12/04/18. On 10/28/19 at 12:43 PM, the findings were discussed with the Administrator. There was no further information provided by the close of the survey on 10/31/19 at 3:00 PM.",2020-09-01
1343,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-10-31,677,E,1,0,OVRC11,"> Based on observation, resident interview, record review, and staff interview, the facility failed to ensure personal care was provided for dependent residents. Residents #49 and #53 did not receive showers as scheduled. Resident #9 was wearing a heavily soiled brief that had fallen around her knees. This was a random opportunity for discovery. Resident identifiers: #49, #53 and #9. Facility census: 191. Findings included: a) Resident #49 An interview with the resident at 11:45 AM on 10/28/19, revealed she did not always get her showers as scheduled. At 10:15 AM on 10/31/19, the resident's shower documentation was reviewed with the assistant director of nursing (ADON) #115. According to the shower schedule, the resident receives showers every Monday and Thursday on the 3-11 shift. In (MONTH) 2019, the resident received scheduled showers until 08/14/19. No showers were recorded after this time period for August. In (MONTH) 2019, the resident received two (2) showers: 09/07/19 and 09/18/19. The documentation revealed the resident refused a shower on 09/21/19. On 09/11/19, the resident received a bed bath. In (MONTH) 2019, the resident received no showers. Documentation revealed only one refusal, 10/28/19. The resident received six (6) of the twenty-six (26) showers scheduled. Two showers were refused. One bed bath was provided instead of the scheduled shower. Only nine (9) of the 26 showers scheduled were accounted for. ADON #115 confirmed the above was the documentation on the shower schedule. b) Resident #53 During the Resident Council Meeting on 10/30/19 at 1:00 p.m. Resident #53 stated she has not been getting her showers like she would like. She stated the shower chair is too high and the shower chair which is the right height was too small and she could not fit into it. She stated the staff did not like to put her on the bench in the shower room and she does not like to use the shower chair that his too high for her so she does not get her showers. A review of Resident #53 medical record found she was scheduled to be showered every Wednesday and Sunday. A review of Resident # 53 Activities of Daily Living Sheets from 08/01/19 thru current found she had not received a single shower. The resident had only bed baths documented for the previous three (3) months with the exception of 09/25/19 where it was documented the resident had refused her shower. A review of the nursing progress notes found Resident #53 also had documented shower refusals on 08/04/19, 08/07/19, 08/21/19, 08/28/19, 09/01/19, 09/18/19, 10/06/19, and 10/16/19. Out of a total of 24 possible showers from 08/01/19 thru current Resident #53 only had 9 documented refusals. An interview with Registered Nurse (RN) #99 at 3:10 p.m. on 10/30/19 confirmed she reviews all shower sheets completed by the Nurse Aides. She indicated, Resident #53 does refuse her showers a lot but the record does not reflect all of her refusals. When asked if the resident had ever mentioned to her that shower chairs were not a good fit for her RN #99 indicated the Resident nor her husband had ever mentioned that. She stated, I think we need to do a better job documenting her refusals. On the morning of 10/31/19 the Nursing Home Administrator (NHA) reported that Resident #53 was documented as refusing her shower yesterday (10/30/19) and when they went to talk to her about her refusal the Resident informed them she wanted her shower and the NA never offered her a shower. The NHA indicated the nurse aide was suspended and they started an investigation. c) Resident #9 On 10/31/19 at 8:55 AM, nursing assistant (NA) #63, delivered the breakfast tray to the resident in her room. NA #63 placed the resident's tray on her over-the-bed table and placed the resident in a sitting position. NA #63 left the resident room to continue serving trays. Resident #9's hospital gown was untied around her neck and the top of the gown was hanging below her neck exposing her white undergarment and her chest. Resident #9's legs were uncovered. An incontinence brief could be seen hanging between her legs, below the hem of the hospital gown, approximately mid-calf. Both could be seen from the hallway. At 10/31/19 at 9:03 AM, the resident's brief and uncovered upper portion of her body was still visible from the hallway and entryway to the resident's room. NA #63 continued to pass breakfast trays and did not return to adjust the resident's clothing and incontinence brief. On 10/31/19 at 9:05 AM, RN #77, Register Nurse (RN), was in the hallway at her med cart. RN #77 entered the residents room to give morning medications. RN #77 did attempt to tie the hospital gown and adjust it so that Resident #9's body was covered; however, RN #77 did not adjust the brief. On 10/31/19 at 9:06 AM, RN #77, confirmed the brief had a foul, strong urine odor and was visible from the hallways. RN #77 stated that she would assist the resident and take care of the incontinence brief. On 10/31/19 at 9:14 AM, the surveyor spoke with the Administrator regarding the findings and no further information was provided before the close of the survey on 10/31/19 at 3:00 PM.",2020-09-01
1344,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-10-31,689,D,1,0,OVRC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to ensure the environment, over which the facility had control, was as free from accidents as possible. This was a random opportunity for discovery. Resident identifiers: #159 and #88. Facility census: 191. Findings include: a) Resident #159 On 10/31/19 at 8:00 AM, a plastic medicine cup with a pink cream was on the nightstand in the resident's room. Observation of the cream found an indentation in the cream which appeared to be made by fingers scooping the cream from the cup. Resident #159 said it was the cream the nursing assistants used on her bottom after providing incontinence care. The resident said the cream had been left out for at least 2 days. Registered Nurse (RN) #77, observed the cream and said it was hydroguard cream. RN #77 said licensed nurses do not apply the cream, only the nursing assistants. RN #77 said the cream should not be left at bedside in a medicine cup. Resident #159's roommate has short-and long-term memory problems due to dementia. The roommate is mobile via her wheelchair. At 8:45 AM on 10/31/19, the findings were presented to the administrator. The administrator provided the Material Safety Data Sheet (MSDS) sheet for [MEDICATION NAME] ointment (the pink ointment at the resident's bedside.) The hazards identified on the MSDS sheet: For external use only. Not for deep puncture wounds. Avoid contact with eyes. Keep out of reach of children. In case of accidental ingestion contact a physician or poison control center immediately. If condition worsens or does not improve within 7 days, consult a doctor. At the close of the survey on 10/31/19 at 3:00 PM, no further information was provided. b) Resident #88 A review of Resident #88's medical record revealed several falls: - 8/19/2019 at 8:45 PM - nurse's note revealed the resident had an unwitnessed fall. Resident was up walking around. - 9/09/2019 at 2:00 PM - fall note revealed the resident had an unwitnessed fall. Resident was ambulating by herself getting into her closet - 9/25/2019 at 7:00 PM - fall note revealed the resident had a witnessed fall. The resident was ambulating without assistance Review of Residents #88's care plan found a focus/problem: Risk for falls and potential for injuries from falls r/t (related to) impaired mobility, muscle weakness, incontinence, cognitive impairment, SOB (shortness of breath), hx (history) falls, [MEDICAL CONDITION] drug use, poor safety awareness, recent left [MEDICAL CONDITION]. The goal associated with this problem: Resident will have no major injury from falls, such as fractures, head injury, or dislocations, through next review period. Interventions included: - Encourage resident to use a reacher when trying to get objects out of their reach. - Place bed in highest position while resident is out of bed to prevent resident from trying to get into bed without assistance. On 10/28/19 at 11:43 AM, observation of Resident #88's room revealed Resident #88's bed was not in the highest position. The resident was not in the room. On 10/28/19 at 11:47 AM, Nursing Assistant (NA) #105 accompanied the surveyor into the resident's room. NA #105 stated that the resident's bed was not in the highest position, and demonstrated by adjusting the bed to the highest position. NA #105 stated that she was unaware that Resident #88 was care planned to have her bed in the highest position when the resident was not in bed. NA #105 was asked if she was aware of the location of Resident #88's reacher. NA #105 looked in the resident's room, drawers, closet, and bathroom and could not locate the resident's reacher. On 10/28/19 at 11:50 AM, Resident #88 was observed eating lunch in the dining room. Resident #88 did not have the reacher in her chair, under her chair, nor on her person. Employee #164, restorative aid, confirmed that Resident #88 did not have her reacher. On 10/28/19 at 11:52 AM, Employee #114, Licensed Practical Nurse (LPN), was asked if Resident #88 attempts to climb into her bed without assistance. LPN #114 stated that Resident #88 does climb in bed when she wants. LPN #114 was asked about placing the bed in the highest position. LPN #114 stated that that bed is never placed in the highest position. On 10/28/19 at 11:59 PM, Employee #210, Minimum Data Set (MDS) Registered Nurse (RN), reviewed the care plan. RN #210 confirmed that the intervention of the bed in highest position has been on the care plan since 12/04/18. On 10/28/19 at 12:43 PM, the findings were discussed with the Administrator. There was no further information provided by the close of the survey on 10/31/19 at 3:00 PM.",2020-09-01
1345,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-10-31,804,D,1,0,OVRC11,"> Based on observation and staff interview, the facility failed to ensure food was served at an appetizing temperature. This had the potential to affect more than a isolated number of residents. Facility census: 191. Findings include: a) Resident Council meeting A resident council meeting was held at 1:00 PM on 10/30/19. Fifteen (15) residents attended the meeting. At least half of the residents who attended the meeting complained about the temperature of the food served at the facility. Residents complained hot foods were not hot and cold food were too hot at the time of service. b) Breakfast temperatures: Observation found the food cart for B hallway arrived on the unit at 8:45 AM on 10/31/19. At 9:06 AM, the dietary manager was asked to take the temperatures of the last tray served from the food cart. The temperatures are as follows: Milk, 54 degrees; Apple Juice, 62 degrees; Cream of wheat, 107 degrees; Biscuits and sausage gravy, 85 degrees. The dietary manager said she would expect the hot food items to be at least 120 degrees and the cold food items to be no more than 41 degrees. b) Noontime Meal The noon time meal on G- Wing of the facility was observed on 10/31/19. The observation began at 12:10 p.m. when the tray cart arrived on the hall. The nurse aides began serving the meals to the residents. At 12:31 p.m. on 10/31/19 the last tray was served and the temperature was obtained from the last remaining tray. The Certified Dietary Manager (CDM) obtained the temperatures for each item and the temperatures were as follows: -- Mashed Potatoes: 112 degrees Fahrenheit -- Country Fried Steak (Chopped) : 109 degrees F -- Green Beans: 109 degrees F The CDM stated that she would like for the temperatures to be above 120 degrees for the hot items.",2020-09-01
1346,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2019-10-31,880,E,1,0,OVRC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, and observation the facility failed to implement an effective infection control program to prevent the development and transmission of communicable diseases and infections. Resident #13, #112, and #194 all had orders for contact isolation. However there was no signage to alert staff, other residents, or visitors that extra percautionswere required when entering the residents room. Also Resident #186's soiled bed linen was placed directly on the floor when the staff member removed them from the bed. These were all random opportunities or discovery. Resident Identifiers: #13, #112, #194 and #186. Facility Census: 191. Findings Include: a) Resident #13 Review of Resident #13's medical record found a physicians order dated 10/29/19 for Contact Precautions. Further review of the record found the resident had a pending laboratory test for [MEDICAL CONDITION] (C- Diff). This was a current order at the time of this review. Observations of Resident #13's room with the Director of Nursing (DON) at 11:20 a.m. and 11:25 p.m. on 10/29/19 confirmed there was no signage to alert staff, visitors, or other residents that extra precautions were required when entering Resident #13's room. The DON confirmed there should have been a sign in the door to alert others of the contact precautions. b) Resident #112 Review of Resident #112's medical record found a physicians order dated 10/23/19 for Contact Precautions due to extended spectrum beta-lactamases (ESBL) in her urine. This was a current order at the time of this review. Observations of Resident #112's room with the Director of Nursing (DON) at 11:20 a.m. and 11:25 p.m. on 10/29/19 confirmed there was no signage to alert staff, visitors, or other residents that extra precautions were required when entering Resident #112's room. The DON confirmed there should have been a sign in the door to alert others of the contact precautions. c) Resident #194 Review of Resident #194's medical record found a physicians order dated 09/19/2019 for Contact Precautions due to C - Diff. This was a current order at the time of this review. Observations of Resident #194's room with the Director of Nursing (DON) at 11:20 a.m. and 11:25 p.m. on 10/29/19 confirmed there was no signage to alert staff, visitors, or other residents that extra precautions were required when entering Resident #194's room. The DON confirmed there should have been a sign in the door to alert others of the contact precautions. d) Resident #186 On 10/31/19 at 10:15 AM, this surveyor was standing in the hallway. Employee #120, nursing assistant, and a hospice nursing assistant were handling linens. Employee #120 walked from behind the privacy curtain and headed towards the sink. Underneath the sink, several linens were observed to be lying in the floor. Employee #120 came from behind the privacy curtain and placed soiled bed linen in the pile on the floor. This linen was not in a bag. Employee #120 then bent down near the pile of linen, a bag in her hand, and proceeded to scoop the linen into the bag, dragging the linen along the floor. During an interview with Employee #120, Employee #120 was asked how staff was supposed to handle dirty linen. Employee #120 stated that staff are to place dirty linen in a bag, not letting it touch the floor. Employee #120 stated that sometimes the linen does get on the floor and sometimes soiled linen is placed in the floor while changing bedding. On 10/31/19 at 10:34 AM, the findings were discussed with the Administrator and a copy of the policy on handling soiled linens were requested. The Administrator provided a copy of the facility policy entitled Handling Soiled Linen. A review of the facility policy entitled, Handling Soiled Linen, revealed there was no implementation date, but the following compliance guidelines were included: 3. a. Linen should not be allowed to touch the uniform or floor. 3. b. Linen should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons. 3. e. Used or soiled linen shall be collected at the bedside and placed in a linen bag., When the task is complete, the bag shall be closed securely and placed in the soiled utility room.",2020-09-01
3804,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2017-04-27,279,D,1,0,0URT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to develop a comprehensive care plan to meet the needs of one (1) of six (6) sample residents. Resident #170's care plan did not address his heart monitor. The resident's care plan only had to use his oxygen as ordered, but there was no order for oxygen. This had the potential to affect no more than an isolated number of residents. Resident identifier: #170. Facility census: 169 Findings include: a) Resident #170 On 04/24/17 at 12:30 p.m., closed record review revealed Resident #170, a [AGE] year-old male, was in the hospital after falling at home and fracturing his right hip. He came to the facility on [DATE] from the hospital. The resident's [DIAGNOSES REDACTED]. According to the resident's medical record, the resident had a heart monitor and oxygen in place at time of admission. The resident's daughter informed the facility that hospital staff placed the heart monitor, belonging to a private doctor, on the resident just prior to him leaving the hospital. An interview with the director of nursing (DON) and an assistant director of nursing (ADON) on 04/26/17 at 1:45 p.m., revealed the resident did have a heart monitor when admitted to the facility. The DON said they had not dealt with that type of heart monitor before, and there had been several issues about its care. A copy of orders for oxygen and for the cardiac monitor, as well as the care plans for the resident's cardiac monitor and oxygen use were requested. On 04/26/17 at 3:24 p.m., the DON and ADON returned and said they could find no orders for the oxygen or the heart monitor. They also reported there was no care plan regarding the heart monitor, and the care plan for oxygen said only to use oxygen as ordered; however, there was no physician's order for the resident to receive oxygen. The DON, when asked about a care plan for the heart monitor, said she did not think they had to have one. When asked, What would guide the staff to know what to do with the monitor and cardiac lead wires when they needed to bathe or shower the resident, the DON replied, Put that way, I guess we did need to care plan it.",2020-08-01
3805,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2017-04-27,309,D,1,0,0URT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure the plan of care for one (1) of six (6) residents reviewed, described the care and services to meet the resident's needs. The plan of care for Resident #170 did not included physician's orders pertaining to oxygen therapy (i.e., rate of flow, delivery method) and did not include orders or instructions regarding the wireless cardiac monitor the resident wore when admitted . Resident identifier: #170. Facility census: 169. Findings include: a) Resident #170 Closed record review on 04/24/17 at 12:30 p.m., revealed Resident #170, a [AGE] year-old male, was admitted from a hospital after falling at home and fracturing his right hip. He came to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a heart monitor in place at time of admission to the facility, which the daughter informed the facility staff belonged to a private doctor, and had been placed on the resident just prior to leaving the hospital. On 04/24/17 at 2:40 p.m., review of the hospital discharge summary dated 02/14/17, found no orders for oxygen or the wireless heart monitor, nor were they included on the physician's orders after admission to the facility. a) Oxygen therapy Review of nursing progress note dated 02/14/16, on 04/24/17 at 1:33 p.m., revealed Patient arrived to the facility via ambulance stretcher. Patient is alert and oriented x3. Patient is on 4L/m (4 liters per minute) via nasal cannula continuously On 04/25/17 at 10:22 a.m., review of a nursing progress note dated 03/12/17 at 19:30 (7:30 p.m.), revealed the family had concerns about the resident's intermittent confusion throughout the day. The family requested to have the physician see the resident by the next day. The nurse noted the resident had labored respirations with little air exchanged heard in the lower lobes and was receiving oxygen at 5 liters per minute via nasal cannula. On 04/25/17 at 10:48 a.m., review of Licensed Practical Nurse (LPN) #117's progress notes dated 02/19/17 and 03/08/17, revealed .O2 NC at 4LPM (on oxygen by nasal cannula at four 4 liters per minute On 04/25/17 at 12:48 p.m., a nursing progress note dated 02/26/17 at 17:44 (5:44 p.m.) included, .episodes forgetfulness . O2 NC 5 LPM (oxygen by nasal cannula at 5 liters per minute), neb tx (nebulizer treatment) as ordered Review of nursing progress notes on 04/25/17 at 2:48 p.m., revealed on multiple occasions, nurses documented the resident was either on oxygen (O2) by nasal cannula at 4 liters per minute or at 5 liters per minute. On 13 different days (02/15/17, 02/18/17, 02/19/17, 02/22/17, 02/23/17, 02/24/17, 03/01/17, 03/02/17, 03/03/17, 03/04/17, 03/05/17, 03/08/17, and 03/09/17) Resident #170 was on oxygen via nasal cannula at 4 liters per minute. Nurses documented during the same period, on eight (8) different days (02/16/17, 02/17/17, 02/20/17, 02/25/17, 02/26/17, 03/10/17, 03/11/17, 03/12/17) Resident #170 was on oxygen via nasal cannula at 5 liters per minute. Review of the resident's physician's orders found no order for oxygen, no order for how many liters per minute the resident should receive and by what device. b) Heart Monitor On 04/25/17 at 11:57 a.m., review of records revealed a late entry dated 02/25/17 at 21:13, (9:13 p.m.) (typed as written) Received call from Heart Monitoring Company who stated that has not received a transmission since 2/15/17. When speaking with company, instructions were given to this nurse on how to check monitor, upon searching the client's room with clients consent, charging cord and [MEDICATION NAME] were found in client's possessions. With the assistance of monitoring staff, was instructed on charging and placement of [MEDICATION NAME]. Several tests performed with monitoring staff on phone and at this time was instructed new cords were needed, and would be sent. to leave monitor attached that some of the signal was coming thru just not very well. Client remains in stable condition, heart rate normal, and respirations even and unlabored, no distress noted. On 04/25/17 at 1:43 p.m., review of a nursing progress note dated 03/02/17 at 21:17 (9:17 p.m.), revealed .Spoke with POA (power of attorney) in regards to heart monitoring device, also spoke with monitoring company, company gave instructions on application of device and several tests were performed, at that time was explained to this nurse that a new monitor would be overnighted for client as the device was defective. Current device remains in place until new can arrive as directed. Client and MPOA (medical power of attorney) is aware of this. On 04/25/17 at 2:18 p.m., review of nursing progress note dated 03/03/17 at 15:51 (3:51 p.m.), revealed the nurse spoke with the heart monitoring company, received new heart monitor today, and with assistance of company, reapplied device. Monitoring company stated monitoring still not performing correctly, and would have to send another out overnight for replacement. Client and POA aware of status of monitor and also notified cardiologist office of status of monitor. Staff will call for instructions to monitoring company when new appliance arrives tomorrow, this communicated to on coming shift. Review of the resident's care plan on 04/26/17 at 12:10 p.m., revealed no focus or interventions/tasks concerning the wireless heart monitor. The oxygen use for [MEDICAL CONDITION] was a focus, however one interventions/tasks was to provide oxygen as ordered. Review of records could not find an order for [REDACTED].>On 04/26/17 at 1:08 p.m., after reviewing the records, the administrator said she could not find an order for [REDACTED]. c) A copy of orders for oxygen and for the cardiac monitor, as well as the care plans for the resident's cardiac monitor and oxygen use were requested. On 04/26/17 at 3:24 p.m., the DON and ADON said they could find no orders for the oxygen or the heart monitor. There was no care plan regarding the heart monitor, and the care plan for oxygen said only to use oxygen as ordered; however, there was no physician's order for the resident to receive oxygen.",2020-08-01
3806,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2017-04-27,441,E,1,0,0URT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a random observation, staff interview, and a posting on a resident's door, the facility failed to ensure staff observed practices to help prevent the development and transmission of disease and infection. During a random observation, a staff member failed to put on protective equipment while interviewing a resident. This practice had the potential to affect more than a minimal number of residents. Resident identifier: #128. Facility census: 169. Findings include: a) Resident #128 Observations on 04/24/17 at 11:10 a.m., noted a droplet precautions sign posted on the door of Resident #128's room. The sign included instructions to perform hand hygiene and put on a surgical mask prior to entering the room and upon leaving the room, to dispose of the mask and perform hand hygiene. During this observation, Social Worker (SW) #229 was interviewing Resident #128, but was not wearing a mask. A few minutes later SW #229 left the room without washing her hands. A physician's orders [REDACTED]. During an interview on 04/25/17 at 1:45 p.m., Assistant Director of Nursing #35, stated she would expect staff to follow droplet precautions' while in the resident's room.",2020-08-01
3893,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,154,D,0,1,0MB311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure Resident #170 was given information in advance sufficient enough for her to make a knowledgeable health care decision in regards to a fluid restriction which her attending physician at the hospital (who was also her attending physician at the facility) had recommended upon her discharge from the hospital on [DATE]. This was true for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT]. Resident Identifier: #170. Facility Census: 178 Findings include: a) Resident #170 A review of Resident #170's medical record at 9:00 a.m. on 09/23/16, found a discharge summary completed by Resident #170's attending physician while she was at the hospital. The discharge summary completed on 08/22/16 included her attending physician recommended a fluid restriction due to her status as a [MEDICAL TREATMENT] patient and her [DIAGNOSES REDACTED]. The same physician was also her attending physician at the facility. During an interview with the corporation's Chief Medical Officer Medical Doctor (CMO-MD) #271 at 10:20 a.m. on 09/23/16, when asked why Resident #170, a [MEDICAL TREATMENT] patient, was not ordered a fluid restriction upon her return from the hospital on [DATE], he replied not every one on [MEDICAL TREATMENT] needed a fluid restriction. He indicated that people in the community very seldom ever restrict their fluid. He proceeded to state the risk and benefits related to not watching her fluid intake was explained to the resident, but she was alert and orientated and able to make her own decisions. Therefore, she had the right refuse the fluid restriction which is why she was not currently ordered a fluid restriction. CFO-MD #271 was then asked if the conversation explaining the risk and benefits related to her refusal of a physician recommended fluid restriction was documented in her medical record. He informed the surveyor that this information did not need to be in the medical record because she was alert and orientated and able to make her own decisions. Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities found the following, 483.10(d)(2) - The resident has the right to be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident's well-being; Interpretive Guidelines 483.10(d)(2) Informed in advance means that the resident receives information necessary to make a health care decision, including information about his/her medical condition and changes in medical condition, about the benefits and reasonable risks of the treatment, and about reasonable available alternatives. At 4:04 p.m. on 09/23/16 the NHA was asked to provide any information that showed Resident #170 was informed about the physician recommended fluid restriction. The Director of Nursing (DON) was also asked at 5:16 p.m. on 09/23/16 to provide the same information. The DON stated she would check with the NHA and let us know. At 5:30 p.m. on 09/23/16, the medical records director reported the DON had told her to let the surveyors know there was no documentation in the medical record related to Resident #170's recommended fluid restriction. During an interview at 4:15 p.m. on 09/23/16, when asked if anyone at the facility had ever talked to her about a fluid restriction Resident #170 said a doctor, who she described as CMO - MD #271, had just been in a little while ago and asked her about a fluid restriction. She stated, I told him that I would not mind being on a fluid restriction if it was what was best for me. She then stated, Then he (she was referring to CMO - MD #271) said not to worry about it because I really did not need one. She then stated, I just want to do what is best for me. When asked if anyone at the facility had ever spoken with her about a fluid restriction prior to that time she stated, No that was the first time they ever mentioned it. On 09/23/16 Resident #170's attending physician declined to be interviewed by the surveyor. The NHA indicated that he was going out of town and was too busy to talk to us.",2020-04-01
3894,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,155,D,0,1,0MB311,"Based on record review and staff interview, the facility failed to establish and maintain policies about a resident's right to refuse treatment. This had the potential to affect all residents currently residing at the facility. Facility Census: 178. Findings Include: a) Policy In the early afternoon of 09/23/16, the Assistant Nursing Home Administrator (ANHA) was asked to provide the facility's policy and/or procedures which were followed when a resident wished to exercise their right to refuse treatment. At 2:44 p.m. on 09/23/16, the ANHA and Nursing Home Administrator (NHA) both confirmed the facility did not have a policy in regards to the residents' right to refuse treatment. They provided the facility's advance directive policy. This policy did include the following statement, Prior to or upon admission of a resident to the facility, the Social Service Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate and advance directive. The remaining eight (8) statements contained in the policy were solely directed to written advanced directives such as medical power of attorney or a living will, and not the right to accept or refuse medical treatment. At approximately 3:00 p.m. on 09/23/16, the Admissions Coordinator #77 was asked to provide what written information was given to residents upon admission to the facility in regards to advance directives and their right to accept and/or refuse medical treatment other than an advance directive. She referred to the facility's Admission Information Packet pages 14 - 26. The information contained on these pages specifically related to the creation of and the authority of written advance directives such as a Medical Power of Attorney or Living Will. It did not include any information pertaining to the residents' right to accept or refuse medical treatment other than the creation of a written advance directive. At 4:04 p.m. on 09/23/16, while reviewing these findings, the NHA was again asked to provide any written policies or procedures related to the residents' right refuse treatment. As of the time of exit, at approximately 7:15 p.m. on 09/23/16, no further information had been provided.",2020-04-01
3895,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,157,D,0,1,0MB311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to notify Resident #170's attending physician when she experienced unrelieved pain and she refused six (6) out of eight (8) [MEDICAL TREATMENT] treatments in the month of (MONTH) (YEAR) due to pain from her [DEVICE]. This was true for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT]. Resident Identifier: #170. Facility Census: 178. Findings include: a) Resident #170 A review of Resident #170's medical record at 10:00 a.m. on 09/21/16 found the resident was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Further review of the record on 09/21/16 at 3:00 p.m., found an admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 08/29/16, identified the resident scored 15 of a possible 15 for the Brief Interview for Mental Status (BIMS) - indicating the resident was cognitively intact. Review of Resident #170's medical records found on multiple occasions Resident #170 refused [MEDICAL TREATMENT] treatments from 09/06/16 through 09/22/16. An interview with Resident #170 at 9:35 a.m. on 09/22/16, revealed she was not going to [MEDICAL TREATMENT] because of pain caused from the [DEVICE] which was placed on 09/05/16. The record contained no information to indicate Resident #170's attending physician and/or nurse practitioner were notified of her refusals of [MEDICAL TREATMENT] and/or pain. The [MEDICAL TREATMENT] center, on two (2) occasions, 08/25/16 and 09/08/16, sent recommendations to discontinue Resident #170's [MEDICATION NAME]. The facility did not address this. She continued to receive the medication and the physician had not been notified of the recommendations as of 09/22/16. In an interview on 09/22/16 at approximately 10:05 a.m., the Director of Nursing (DON) was informed of Resident #170's multiple documented occasions when the resident refused [MEDICAL TREATMENT] treatments from 09/04/16 through 09/22/16, and the resident interview in which she stated she was refusing [MEDICAL TREATMENT] due to pain caused by the wound vac. The lack of notification of the attending physician and/or nurse practitioner was also brought to her attention at that time. Additionally, the DON was informed the [MEDICAL TREATMENT] center had sent recommendations to discontinue Resident #170's [MEDICATION NAME] on two (2) occasions, 08/25/16 and 09/08/16, which had not yet been addressed by the facility. The resident continued to receive this medication and the physician had not been notified of the recommendations as of 09/22/16. No further information provided prior to exit. Attempts to interview Resident #170's attending physician on 09/22/16 and again on 09/23/16 were unsuccessful. The NHA reported the physician said he was too busy and did not have time to speak with surveyors.",2020-04-01
3896,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,163,D,0,1,0MB311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure Resident #170 was afforded the right to choose her personal physician upon admission to the facility. This was true for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT]. Resident Identifier: #170. Facility Census: 178. Findings Include: a) Resident #170 A review of Resident #170's medical record at 4:00 p.m. on 09/23/16, found she had two (2) recent admissions to the facility. She was admitted on [DATE], discharged to the hospital 08/12/16 and was readmitted on [DATE]. Review of the admission orders [REDACTED]#272). Resident #170's record contained a history and physical completed by DO #272 which on 08/23/16. This History and Physical contained the following statement, Patient admitted to my services but requests to be changed to (Name of attending Medical Doctor (MD) #273 as he is her regular provider. Review of the nursing progress notes found a note dated 08/27/16 at 9:42 a.m. stating, (Name of MD #273) arrived at facility identifying patient as a long time patient of his, he requested patient be switched from (Name of DO #272) to his care in facility. Also contained in Resident #170's medical record was a form titled, Consent for Treatment and Release of Information. This form indicated that Resident #170 had designated MD #273 as her attending physician, however his name was marked out and replaced with DO #272's name. This form was signed by the resident on 08/12/16. The name of the physician was changed by the nurse completing the form and it was unknown if it was done prior to or after the resident signed the form. An interview with Resident #170 at 4:15 p.m. on 09/23/16, confirmed she was not given a choice of physician upon admission to the facility. She stated, I had one Doctor when I first got here because I did not know (Name of MD #273) came here. When I found out he came here I told them I wanted to be switched and they switched me. She stated, He has been my Doctor for a long time and he knows all about me and I really like him. An interview with the Director of Nursing (DON) at 4:44 p.m. on 09/23/16, confirmed Resident #170 was admitted to the services of DO #272 upon her admission on 08/12/16 and 08/22/16. She stated that the nurses are to list the names of all three physician's and let the resident choose which physician they want. She confirmed Resident #170 was not switched to MD #273's services until 08/27/16 when MD #273 visited the facility and requested she be changed to his services.",2020-04-01
3897,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,241,D,0,1,0MB311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain or enhance each resident's dignity as evidenced by staff using labels in reference to the resident's feeding ability. This affected one (1) randomly observed resident. Resident identifier: #388. Facility census: 178. Findings include: a) Resident #388 On 09/19/16 at 11:51 a.m., Resident #388 sat in a chair between his bed and the doorway. He wore a hospital gown, and a blanket covered his shoulders and upper arms. Numerous covered food items sat on an over-bed table in front of him. Nurse Aide (NA) #195 stood at the roommate's bed and opened the tray for the roommate. Another staff person entered the room to see if the resident's needed help. NA #195 relayed to the other staff person that Resident #388 was a feeder. This statement could be heard in the hallway outside the resident's room. Medical record review on 09/21/16 at 2:00 p.m. found this resident recently came to the facility. The admission minimum data set (MDS) assessment, with an assessment reference date (ARD) 09/14/16, assessed Resident #388 with severely impaired cognitive skills. Section G of the MDS assessed need for extensive staff assistance with bed mobility and transfer, dressing, eating, toilet use, personal hygiene, and total dependence for bathing. [DIAGNOSES REDACTED]. Section K of the MDS assessed feeding difficulties which included the loss of liquids or solids from his mouth when eating or drinking; holding food in his mouth or cheeks, or residual food in his mouth after meals; and coughing or choking during meals or when swallowing medications. Subsequently, he required a mechanically altered diet. During an interview with the director of nursing (DON) on 09/21/16 at 3:30 p.m., she said that referring to a resident as a feeder was not an acceptable practice at this facility. She spoke her belief that staff knew better than to do that, because this is a dignity issue.",2020-04-01
3898,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,250,D,0,1,0MB311,"Based on resident interview and staff interview, the facility failed to assist Resident #235 in maintaining or improving her ability to manage her everyday psychosocial needs. Social services failed to discuss with resident concerns arising from a visitor visiting after recommended visiting hours. This was true for one (1) of four (4) residents reviewed for choices. Resident identifier: #235. Facility Census: 178 Findings include: a) Resident #235 During a Stage 1 interview on 09/19/16 at 3:20 p.m., Resident #235 revealed a friend came to visit her late one night. The resident stated they (her friend and Resident #235) had both worked as night shift nurses for years, and at night was the only time her friend could visit. The resident said they went to the dining room and even outside during the visits, so as not to disturb any of the other residents. Resident #235 stated her friend was badly scolded on two (2) different occasions for visiting late in the night and was made to feel like a child. The night shift supervisor made her leave the first time, and her friend called the administrator to make sure it was alright to visit at night, if they did it quietly and did not disturb other residents. Her friend was told by the administrator that she could visit, but did need to be respectful of other residents. The friend came back around 1:00 a.m. to visit the next night after clarifying with the Administrator it was all right to visit. According to the resident, the night shift supervisor stopped the visit again. The resident stated, The supervisor brought a second nurse with her. The second nurse stood behind the supervisor with her arms folded across her chest while the supervisor yelled at my friend. The supervisor told my friend, you are a nurse and should know better. We have patients here that need their sleep. Resident #235 stated her friend was upset and embarrassed and demanded an incident report be filled out. When asked if an incident report had been filled out, the resident said, Yes, I think so. I don't know what it said, but I saw my friend sign a paper before she left. The resident related the friend had not returned to visit her since the second incident. The resident was extremely upset over the matter. Resident #235 stated, I don't have very many visitors to start with, and now my friend will not come to see me at all for fear the staff will jump on her again. The resident said the incident occurred about two (2) weeks ago. On 09/22/16 at 8:32 a.m., review of various reports including grievances, incidents, accidents, concerns, and reportable occurrences for the last three (3) months did not find any reports mentioning the late night visit occurrence described by Resident #235. Social Worker #134, interviewed on 09/22/16 at 8:53 a.m., revealed she had just recently moved to that side of the building and was not yet unfamiliar with any of the residents residing there. The social worker had no knowledge of any incidents concerning Resident #235 regarding having visitors at night. An interview with the director of nursing (DON) on 09/22/16 at 9:05 a.m., revealed she was aware of an issue concerning a friend of Resident #235 visiting late into the night. The DON stated she knew of the visit, but did not know the visitor was asked to leave. On 09/22/16 at 9:09 a.m., the DON accompanied the surveyor to Resident #235 room to talk to the resident about the incident. The resident told the surveyor and the DON the same story about her friend's visits she originally told the surveyor, and was adamant her friend filled out an incident form because her friend had demanded one be filled out. After the interview with the resident the DON stated she was not aware of any incident report. The DON said, The staff let me know because it is not typical to have visits in middle of night. The staff probably felt like she (visitor) shouldn't be here at that time. The DON went on to say she would make sure the nurses knew it was okay to have visitors at any time as long as they are not disruptive to other residents. An interview with the Administrator, on 09/22/16 at 9:21 a.m., revealed she knew about the friend's visit because Resident #235's friend had called the Administrator. The Administrator said, .the friend was made to feel she should not visit. I told the friend on the phone she could visit, but did need to be respectful of the other residents, and to let staff know if they went outside on the grounds. The Administrator said, I was never told anything else about it. I did not know there was a second visit. This was not typical of Resident #235 to have visitors at night and this just started happening. I did nothing else with it. I never talked to the resident about it. On 09/22/16 at 10:02 a.m., an interview with the Administrator, and Social Worker #134, revealed the Administrator felt the phone call was all about the friend not the resident. The administrator said, .basically the friend was checking with me because she (the friend visitor) was made to feel, by the staff, she shouldn't be here visiting at night. Since the friend had called me, and talked only about her (friend's) concerns of whether she could visit during the night or not, I did not feel I needed to discuss it with the resident. When the Administrator was asked, if she thought Resident #235 was an involved participant of the visits. should she have been followed up with? The Administrator looking over at Social Worker #134, said we will go now and talk with the resident.",2020-04-01
3899,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,253,E,0,1,0MB311,"Based on observation, random observation and staff interviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The cosmetic imperfections included peeling wallpaper, damaged chair railing, missing caulking around sinks and commodes, damaged sink tops, a light casement and cable box had pulled away from wall, missing paint, broken and stained floor tiles, and odors. Room identifiers: A1, A3, C1, C3, C5, C12, D4, D5, D7, D8, D9, E5, F11, G2, and G13. Facility census: 178. Findings include: a) Cosmetic imperfections --Room A1 - observed on 09/19/16 at 2:48 p.m., had wallpaper peeling away from the wall above resident's bed. --Room A3 - observed on 09/19/16 at 2:37 p.m. - the chair had scuffed arms. --Room C1 - observed on 09/20/16 at 9:54 a.m. - had torn wallpaper behind resident's bed. --Room C3 - observed on 09/20/16 at 9:23 a.m. - had splintered chair railing behind the resident's bed, a sink top with damaged Formica, and a cracked board above the cove base. --Room C5 - observed on 09/20/16 at 8:41 a.m. - had splintered chair railing behind the bed and the board above the cove base was splintered. --Room C12 - observed on 09/20/16 at 10:18 a.m. - had chair railing and wallpaper separated from the wall, walls had missing paint, and the entrance door had peeled paint. --Room D4 - observed on 09/20/16 at 12:44 p.m. - had broken floor tile under the sink, the light housing over the bed had pulled away from the wall and the walls had areas of paint, that did not match. --Room D5 - observed on 09/20/16 at 8:44 a.m. - had a dirty heating/cooling unit and stains around the base of the commode. --Room D7 - observed on 09/20/16 at 8:49 a.m. - had a sink with missing caulking and the front of the sink top had been poorly repaired. --Room D8 - observed on 09/20/16 at 9:07 a.m. - had a sink with missing caulking. --Room D9 - observed on 09/20/16 at 9:52 a.m. - had a closet door with scuff marks. --Room E5 - observed on 09/20/16 at 9:42 a.m. - had a commode needing the caulking replaced. --Room F11 - observed on 09/20/16 at 10:00 a.m. - had a sink with cracked and missing caulking. --Room G2 - observed on 09/20/16 at 9:32 a.m. - had a sink with cracked and missing caulking. --Room G13 - observed on 09/20/16 at 9:56 a.m. - had wallpaper separating from the wall, the cable box had pulled away from the wall and the chair railing was pulled away from the wall. b) Interview with the Maintenance Supervisor On 09/22/16 at 2:10 p.m., the Maintenance Supervisor verified the peeling wallpaper, damaged chair railing, missing caulking around sinks and commodes, the damaged sink tops, a light casement and cable box, had pulled away from wall, missing paint, broken and stained floor tiles. He agreed all the cosmetic imperfections needed to be repaired, replaced or repainted. c) Resident #225 On 09/21/16 at 3:17 p.m., a random observation revealed a foul odor coming from Resident #225's room. An additional observation on 09/21/16 at 5:17 p.m. revealed a foul odor still coming from Resident #225's room. Upon examination by Licensed Practical Nurse (LPN) #148 the resident's brief was dry and the catheter leg bag was intact with no leakage. No odors were noted in the bathroom or closet area. LPN #148 agreed there was a foul odor in the room which was strongest around Resident #225's bed. In an interview, on 09/21/16 at 5:34 p.m. with Unit Manager (UM) #164 regarding the odor in the room, she stated the resident often refused showers or bed baths. She also stated housekeeping would be notified to clean the room and replace the floor mats beside the bed. On 09/21/16 at 5:35 p.m., the Administrator (NHA) stated in an interview she was not aware of any housekeeping issues in Resident #225's room. On 09/22/16 at 8:00 a.m. an additional observation of Resident #225's room was found to be clean and free from odors. Housekeeping Supervisor (HS) #187 and UM #164 stated Resident #225 now had a new mattress. In addition, the UM #164 stated a large rectangular yellow stained area was found near Resident #225 s roommate's bed. The UM #164 agreed the floor mat had covered the large rectangular yellow stained area and could have been contributing to the foul odor in the room. An additional observation with UM #164 on 09/22/16 at 9:45 a.m., revealed Resident #225's floor was clean and the room was without any foul odor.",2020-04-01
3900,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,279,D,0,1,0MB311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop individualized and measurable goals for a resident with behaviors, who was treated with psychoactive medications. This was evident for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #225. Facility census: 178. Findings include: a) Resident #225 Medical record review on 09/21/16 at 1:30 p.m., found this [AGE] year-old resident had [DIAGNOSES REDACTED]. disorder, depression, mood disorder, [MEDICAL CONDITION], and [MEDICAL CONDITION] other than [MEDICAL CONDITION]. Daily medications included [MEDICATION NAME] (an antianxiety medication) one (1) milligram (mg) three (3) times daily; [MEDICATION NAME] (antipsychotic medication) twenty-five (25) mg daily at bedtime; and [MEDICATION NAME] (an antidepressant medication) fifteen (15) mg daily at bedtime. The most recent quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) off 07/22/16, assessed he received antipsychotic, antianxiety, and antidepressants daily. The Brief Interview for Mental Status (BIMS) assessed his score as three (3), which indicated severely impaired cognition for decision-making. Review of the care plan found a problem/focus that the resident received antipsychotic medication due to a [DIAGNOSES REDACTED]. It noted the resident exhibited mood changes for no apparent reason, and could become upset and aggressive. Also he resisted and/or refused activities of daily living care at times, hit staff, cursed and yelled. The care planned goal for this problem simply stated Resident will receive lowest dose possible with no side effects noted through next review period. The care plan contained another focus/problem area that he received antianxiety medication related to behaviors of agitation as evidenced by hitting staff, cursing and yelling, due to the [DIAGNOSES REDACTED]. Further review of the care plan found a focus/problem that he received antidepressant medication as an appetite stimulant and for the risk for decline in mood status and/or side effects. The care planned goal for this problem stated Resident will have no unidentified complications related to medications usage/side effects. In an interview with the director of nursing (DON) on 09/21/16 at 3:30 p.m., she reviewed the goals for the use of the antianxiety, antidepressant, and antipsychotic medication. When asked about the goal for the use of those medications, she read the care planned goals for him to be on the lowest dose of medication. When asked what the goals were for his targeted behaviors of mood changes, agitation, hitting staff, cursing, yelling, and resistance to care, she said she was unable to tell by the care plan. Upon inquiry, she acknowledged that the goals for the psychoactive medication use and behaviors were not individualized or measurable, but rather instead were more interventions/tasks for the use of the medications.",2020-04-01
3901,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,280,D,0,1,0MB311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #179's care plan was revised when her order for a fluid restriction was discontinued. This was true for one (1) of four (4) residents reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #179. Facility Census: 178. Findings Include: a) Resident #179 A review of Resident #179's medical record at 2:43 p.m. on 09/20/16, found a physician's orders [REDACTED]. A review of Resident #179's current care plan at 3:00 p.m. on 09/20/16, found a focus statement related to the resident's risk for altered nutritional and hydration status. The interventions related to this focus statement included, Provide a 1000 ml per day fluid restriction per md (medical doctor). An interview with the Director of Nursing (DON) at 2:12 p.m. on 09/21/16 confirmed the resident's care plan needed revised because she was no longer on a fluid restriction.",2020-04-01
3902,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,309,H,0,1,0MB311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, and resident interview the facility failed to assess Resident #170's pain by location, quality, intensity, pattern, frequency, timing, and duration. There was no evidence the facility attempted to develop interdisciplinary nonpharmacological strategies to manage the resident ' s pain. The resident suffered actual harm by the facility's failure to ensure the most effective pain management possible for the resident. Review of Resident #170's medical records, staff interviews and resident interviews found on multiple occasions from [DATE] through [DATE] the resident had refused [MEDICAL TREATMENT] treatments. An interview with Resident #170 revealed she was not going to [MEDICAL TREATMENT] because of pain caused from the [DEVICE], which was placed on [DATE]. The record contained no information to indicate Resident #170's attending physician and/or the nurse practitioner were notified of her refusals of [MEDICAL TREATMENT] and/or pain. On [DATE] and [DATE], the [MEDICAL TREATMENT] center sent recommendations to discontinue Resident #170's [MEDICATION NAME]; however, she continued to receive this medication and the physician had not been notified of the recommendations as of [DATE]. Additionally, for Resident #170, the facility failed to correlate care between the facility and the [MEDICAL TREATMENT] center and failed to administer the Renavela as directed by the nephrologist. For Resident #225, the facility failed to provide effective pain management by failing to assess his level of pain prior to the administration of an as needed (PRN) pain medication. The facility failed to reassess the resident to determine the effectiveness of the pain medication. These issues were found for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT] and for one (1) of five (5) reviewed for the care area of unnecessary medications. Resident identifier: #170 and #225. Facility census: 178. Findings include: a) Resident #170 A review of Resident #170's medical record at 10:00 a.m. on [DATE] found the resident was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The medical record, reviewed on [DATE] at 3:00 p.m., found an admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], identified the resident scored 15 of a possible 15 for the Brief Interview for Mental Status (BIMS) - indicating the resident was cognitively intact. Review of the nurses' progress notes found Resident #170 was admitted to the facility on [DATE] at 5:35 p.m. Further review of the nursing progress notes found a note written by Licensed Practical Nurse (LPN) #282, LPN, on [DATE] at 4:55 p.m. stating, Worsening [MEDICAL CONDITION] to bilateral lower extremities and resident missed [MEDICAL TREATMENT] yesterday. The resident has orders for the following advance directives: CPR (cardiopulmonary resuscitation). Resident admitted to this facility on [DATE]. Skin warm and dry. Respirations even and non-labored. Denies cough or shortness of breath. Resident is becoming short of breath when lying flat or turning in bed. Oxygen saturation is 96% (percent) on room air. Observed 3+ (plus) [MEDICAL CONDITION] to bilateral lower extremities. Notified the NP earlier today with no new orders received. As day has progressed, [MEDICAL CONDITION] has worsened and is now non-pitting. Resident states she was due [MEDICAL TREATMENT] yesterday and was not sent. A progress note written on [DATE] at 11:21 p.m. by Registered Nurse (RN) #199 noted, Per (Name of Hospital) was admitted to hospital for [MEDICAL TREATMENT], [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #170 was re-admitted to the facility on [DATE] after receiving treatment for [REDACTED].#273). Physician orders [REDACTED].#273) read: --Wound care per previous orders. --Daily weight, report increase in [MEDICAL CONDITION] or shortness of breath to physician (#273) --Follow-up at facility by attending physician (#273) --[MEDICAL TREATMENT] as previous (Tuesday, Thursday and Saturday) --Transferring physician (#273) and admit to facility under my service. --admitting [DIAGNOSES REDACTED]. --Code status: Full Code --[MEDICATION NAME] coated Aspirin 81 mg by mouth daily. --[MEDICATION NAME] 50mg by mouth at bedtime --[MEDICATION NAME] 50 mcg topically every three (3) days. --[MEDICATION NAME] 17 grams by mouth every day. --[MEDICATION NAME] 12.5 mg by mouth twice daily, (Hold if systolic blood pressure is 100 or below). --[MEDICATION NAME] 10mg by mouth daily --[MEDICATION NAME] 40 mg by mouth daily --[MEDICATION NAME] 7.5 mg by mouth at bedtime --[MEDICATION NAME] 3,200 mg by mouth three times daily with meals. --[MEDICATION NAME] 200mg by mouth three times daily --[MEDICATION NAME] 50 mcg by mouth daily --Dosage of [MEDICATION NAME] will be advised after looking at the [MEDICATION NAME] time/international ratio (PT/INR) tomorrow ([DATE]) --[MEDICATION NAME] 0.25 mg by mouth daily -- Fluid restrictions --[MEDICATION NAME] 325 mg by mouth three times daily --[MEDICATION NAME] ,[DATE] mg by mouth every 6 hours prn Review of the readmission orders [REDACTED]. No orders for fluid restrictions could be found. Additionally, a review of the MAR for ,[DATE] and ,[DATE] found the medication [MEDICATION NAME] was administered at 6:00 a.m., 2:00 p.m., and 10:00 p.m. This medication should have been, administered at meal times which would have been 7:30 a.m., 12:00 p.m. and 5:30 p.m. Review of the Physician Desk Reference (PDR) read, [MEDICATION NAME](R) (sevelamer [MEDICATION NAME]) is indicated for the control of serum phosphorus in patients with [MEDICAL CONDITION] (CKD) on [MEDICAL TREATMENT]. [MEDICATION NAME] (sevelamer) is a [MEDICATION NAME] binder that helps prevent [DIAGNOSES REDACTED] (low levels of calcium in the body) caused by elevated phosphorus. This medication should be taken with meals. During an interview on [DATE], at approximately 3:15 p.m., with local [MEDICAL TREATMENT] center's medical director (nephrologist), it was confirmed the [MEDICATION NAME] should be given with meals otherwise the medication is useless. Further review of the record found a new patient history and physical completed on [DATE] by Physician #272 read, Patient Was admitted from (Name of hospital #1) with a [DIAGNOSES REDACTED].Patient was admitted to my services but resident requests to be changed to (Name of physician #273) as he is her regular doctor. Continue current pain regimen. Staff to monitor for pain per facility policy. [MEDICATION NAME] ,[DATE]mg by mouth every six (6) hours prn for pain. A Consultation Report written on [DATE] by Physician #275, vascular and wound care specialist included, Non-ambulatory. Sacral ulcer - 4 centimeters (cm) in length and 3 cm in width. Stage III - IV (Stage 3 to 4). The right heel is fully healed. + (positive) Coagulant ([MEDICATION NAME]). Plan - Needs to change dressing to a [DEVICE] to the sacral ulcer. Review of the Treatment Administration Record (TAR) for the month (MONTH) (YEAR) found the following, Cleanse Stage IV pressure ulcer to sacrum with IHWC (In House Wound Cleanser), pat dry, apply wound vac (vacuum) @ (at) 125 mm/hg (millimeters of mercury) every 3 (three) days and prn (as needed) This had a start date of [DATE]. Review of Resident #170's [MEDICAL TREATMENT] record from [DATE] to [DATE] found the following: --From [DATE] to [DATE]- Resident #170 was ordered a 240 minute [MEDICAL TREATMENT] treatment three times a week. The following occasions are the actual days and times Resident #170 received [MEDICAL TREATMENT]. --[DATE]- 190 minutes of treatment. --[DATE]- 208 minutes of treatment --[DATE]-239 minutes of treatment --[DATE]- 236 minutes of treatment --[DATE] through [DATE]- Resident hospitalized --[DATE]- 206 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]-219 minutes of treatment --[DATE]- 244 minutes of treatment --[DATE]- 196 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]-0 minutes of treatment --[DATE]-237 minutes of treatment --[DATE]- 233 minutes of treatment --[DATE]- 137 minutes of treatment --[DATE]- 200 minutes of treatment --[DATE]- 89 minutes of treatment --[DATE]- 242 minutes of treatment --[DATE] through [DATE]- Resident was hospitalized --[DATE]- 149 minutes of treatment --[DATE]- 253 minutes of treatment --[DATE]- 241 minutes of treatment --[DATE]- 145 minutes of treatment --[DATE]- 173 minutes of treatment --[DATE]- 255 minutes of treatment --[DATE]- 175 minutes of treatment --[DATE]- 93 minutes of treatment --[DATE]- 236 minutes of treatment --[DATE]- 212 minutes of treatment --[DATE]- 179 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 237 minutes of treatment --From [DATE] through [DATE] Resident #170 was ordered a 210 minute [MEDICAL TREATMENT] treatment three times a week. The following are the actual dates and times she received [MEDICAL TREATMENT]. --[DATE]- 215 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE] through [DATE]- Resident hospitalized . -- [DATE] 0 minutes of treatment ( A nurses noted dated [DATE] that the resident stated to the nurse, she was due [MEDICAL TREATMENT] yesterday and was not sent. Resident #170 later that day was sent to the hospital and was admitted for [MEDICAL TREATMENT], [MEDICAL CONDITION], and [MEDICAL CONDITION]) --[DATE] through [DATE]- Resident hospitalized --[DATE]- 217 minutes of treatment --[DATE]- 214 minutes of treatment --[DATE]- 210 minutes of treatment --[DATE]- 211 minutes of treatment --[DATE]-100 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 210 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 79 minutes of treatment -- [DATE] - 0 minutes of treatment. --[DATE]- 0 minutes of treatment From [DATE] through [DATE], the resident had the opportunity to go to the [MEDICAL TREATMENT] center for her [MEDICAL TREATMENT] treatment 38 times, excluding the times the resident was in the hospital. Of those 38 opportunities, Resident #170 missed only 6 treatments (or 16%) in their entirety. Upon placement of the wound vac on [DATE] through present, Resident #170 had the opportunity to go to [MEDICAL TREATMENT] a total of eight (8) times. Of those eight (8) opportunities, the resident missed 6 (or 75%) of those treatments in their entirety. During an interview with Chief Medical Officer (CMO) #271 at 10:20 a.m. on [DATE], he stated that Resident #170 had a long history of refusing [MEDICAL TREATMENT]. During an interview at 12:13 p.m. on [DATE], Medical Director #272 also mentioned Resident #170 had a long history of refusing [MEDICAL TREATMENT]. (The resident ' s attending physician was not available for interview.) These statements were not supported by the local [MEDICAL TREATMENT] centers ' records that showed Resident #170 only missed 6 of 38 possible treatments from [DATE] through [DATE]. However, after the wound vac placement, she missed 6 of the 8 possible treatments from [DATE] through [DATE] because of what she stated to be pain caused by the wound vac. Review of Resident #170 ' s [MEDICAL TREATMENT] records from [DATE] through [DATE], review of Missed HD ([MEDICAL TREATMENT]) treatment reports, and staff interviews, found that beginning on [DATE] through [DATE] Resident #170 either missed or had her [MEDICAL TREATMENT] treatments cut short for the following reasons: -- On [DATE], a nursing progress note indicated, Resident refused [MEDICAL TREATMENT]. States she does not feel good. -- [DATE], a nursing progress note included, Patient went to [MEDICAL TREATMENT] today. Explained the importance of her completing her [MEDICAL TREATMENT] treatment completely for her heath. Patient agreed to go and would try to complete treatment today. Review of Resident #170 ' s Missed HD Treatment Report, found she only received [MEDICAL TREATMENT] for 210 minutes of her scheduled 210-minute treatment. -- [DATE] (a non-[MEDICAL TREATMENT] day), a nursing progress note included, Resident c/o (complains of) wound vac hurting her. Wing nurse notified and resident stated she was medicated. (Name of MD #275) notified and decreased intensity to 50 mmHg per order for two hours and resident continued to c/o the wound vac bothering her and request it be taken off. (Name of MD #275) notified and gave order to hold vac and gave dressing orders until Sunday if he comes and if not, he will evaluate when next in facility. Resident aware. -- [DATE], a nursing progress note indicated, Resident refused to go to [MEDICAL TREATMENT]. States her back is hurting. -- [DATE] a nurse wrote, Resident agreed to resume wound vac to sacrum. Applied wound vac with no s/s (signs or symptoms) of pain or complications will continue to monitor -- [DATE], a nursing progress note contained, .Goes to [MEDICAL TREATMENT] Tues., Thurs., and Sat; however resident refused this morning d/t (due to) wound vac for sacral ulcer. Often refuses to go to [MEDICAL TREATMENT] -- [DATE], a nurse documented, Patient refused to go to [MEDICAL TREATMENT] after 3 attempts by the nurse to get her to go. Attempted to explain the importance of completing her [MEDICAL TREATMENT] treatment but she continuously refuses. -- No nursing notes for [DATE]. However, the [MEDICAL TREATMENT] Communication record described the resident was experiencing pain and was crying until her treatment was stopped per her request. She only completed 79 minutes of her 240 minute treatment. -- No nursing progress notes for [DATE] pertaining to Resident #170 ' s [MEDICAL TREATMENT] treatment, however the Missed HD Treatment Report indicated the resident did not go to [MEDICAL TREATMENT] on that date. -- No nursing progress noted for [DATE], however the Missed HD Treatment Report indicated the resident did not go to [MEDICAL TREATMENT] on that date. Resident #170 missed a total of six (6) of her last eight (8) [MEDICAL TREATMENT] treatments since the placement of the wound vac on [DATE]. Of the two (2) treatment she did attend, she only completed one full treatment. On [DATE] the resident ' s [MEDICAL TREATMENT] treatment was cut 131 minutes short. There was no evidence in Resident #170's medical record that her attending physician was notified of her missed [MEDICAL TREATMENT] treatments and/or of her increased pain associated with the use of her wound vac. A review of Resident #170's controlled medication sheets for her ordered as needed [MEDICATION NAME] found the following: -- [DATE] the resident refused to go to [MEDICAL TREATMENT] due to pain. She was scheduled to leave for [MEDICAL TREATMENT] at 5:30 a.m. however she only received two (2) doses of [MEDICATION NAME] on this date one (1) at 12:00 p.m. and one (1) at 9:00 p.m. -- [DATE] Resident #170 left [MEDICAL TREATMENT] early due to pain. She did not receive her as needed pain medication until 9:00 p.m. -- [DATE] Resident #170 refused to go to [MEDICAL TREATMENT], which she was scheduled to be picked up for at 5:30 a.m. because of back pain. She did not receive her as needed pain medication until 6:00 a.m. she also received additional doses at 1:30 p.m. and 9:00 p.m. -- [DATE] Resident #170 refused to go to [MEDICAL TREATMENT] due to pain from her wound vac. The resident's pick up time for [MEDICAL TREATMENT] was at 5:30 a.m. She did not receive her as needed pain medication until 6:00 a.m., 12:00 p.m., and 9:00 p.m. -- [DATE] the patient had refused to go to [MEDICAL TREATMENT] after 3 attempts. She did not receive pain medication until 10:30 a.m. and 5:30 p.m. (Please note - the nursing note did not mention why the resident refused [MEDICAL TREATMENT]; however, interviews with the resident confirmed she had been refusing [MEDICAL TREATMENT] due to pain from the wound vac. -- [DATE] - Resident #170 returned from [MEDICAL TREATMENT] after only receiving a 79 minutes treatment when she was scheduled to receive a 210 minute treatment. The [MEDICAL TREATMENT] center wrote on the communication form that Resident #170's treatment had to be stopped because she was crying in pain. She arrived back to the facility at approximately 9:00 a.m. and she received pain medication at 4:30 a.m. and 5:30 p.m. on that day. -- [DATE] Resident #170 refused to go to [MEDICAL TREATMENT] she did not receive pain medication until 9:00 a.m. and 9:00 p.m. even though her scheduled pick up time for [MEDICAL TREATMENT] was 5:30 a.m. -- [DATE] Resident #170 again refused to go to [MEDICAL TREATMENT]. She had receive pain medication at 4:40 a.m. on that date. -- [DATE], [DATE], and [DATE], the location of the resident's pain was not noted in the medical record. She did however refuse [MEDICAL TREATMENT] on those dates. In an interview with Resident #170 on [DATE] at 9:35 a.m., she said she did not go to [MEDICAL TREATMENT] today due to her wound vac hurting. She further explained she had chronic pain, but since they started the wound vac, she had experienced more pain and discomfort, and she had told staff that was the reason she could not go to [MEDICAL TREATMENT]. She added she had had to miss several of her [MEDICAL TREATMENT] treatments due to pain. During an earlier interview on [DATE] at 1:10 p.m. with a different surveyor, Resident #170 had stated that she had not been going to [MEDICAL TREATMENT] because of the pain she was experiencing from her wound vac. On [DATE], Resident #170's [MEDICAL TREATMENT] treatment ended after 79 minutes due to complaints of pain as noted by the [MEDICAL TREATMENT] clinic. At 1:35 p.m. on [DATE], the clinical director of the local [MEDICAL TREATMENT] center was interviewed. When asked if the facility needed to set up a new chair time (scheduled time for [MEDICAL TREATMENT] at the [MEDICAL TREATMENT] center) when Resident #170 was admitted to their facility she replied, No we do not give up their chair time when they are in the hospital. She stated, she would have had the same chair time and no arrangements were needed. When asked why Resident #170's treatment was cut short on [DATE] she stated, Because of pain related to her wound vac. She also indicated that was why the resident's treatment was cut short on [DATE]. She said Resident #170 had at times refused [MEDICAL TREATMENT] prior to the placement of the wound vac, but since its placement, her refusals had increased drastically. Further review of the Resident #170's controlled substance utilization record found Resident #170 was administered her prescribed as needed pain medication with no assessment of where the pain was located, the intensity of the pain prior to administration, and no follow up assessment to determine if the pain medication was effective in relieving the resident's pain. This was found for the following dates and times: -- [DATE] at 10:00 a.m. and 6:00 p.m. -- [DATE] at 12:00 a.m., 1:00 a.m., and 9:10 p.m. -- [DATE] at 4:30 a.m. and 9:00 p.m. -- [DATE] at 10:00 p.m. -- [DATE] at 9:00 a.m. and 9:00 p.m. -- [DATE] at 9:00 a.m. (Not noted on MAR) and 9:00 p.m. -- [DATE] at 5:00 a.m. (Marked not given, Wasted on Narcotic sheet), 12:00 p.m. and 9:15 p.m. (Not recorded on MAR). -- [DATE] at 7:00 a.m. and 6:00 p.m. -- [DATE] at 12:00 a.m. (Not recorded on MAR at 2:00 p.m. and 10:00 p.m.) -- [DATE] at 6:20 a.m. and 10:00 p.m. -- [DATE] at 12:00 p.m. and 9:30 p.m. -- [DATE] at 1:25 p.m. (Not recorded on MAR) and 8:00 p.m. -- [DATE] at 5:30 a.m., 11:30 a.m. (Not recorded on MAR) and 6:00 p.m.( Not recorded on MAR) -- [DATE] at 12:00 p.m., and 9:00 p.m. (Not recorded on MAR) -- [DATE] at 9:00 a.m., 4:30 p.m. and 11:00 p.m. (Not recorded on MAR) -- [DATE] at 9:00 p.m. -- [DATE] at 11:00 a.m. and 5:00 p.m. -- [DATE] at 6:00 a.m., 1:30 p.m., and 9:00 p.m. -- [DATE] at 6:30 a.m., 2:30 p.m. (Not recorded on MAR) and 10:30 p.m. -- [DATE] at 9:30 a.m. (Not recorded on MAR) and 9:00 p.m. -- [DATE] at 6:00 a.m. (Not recorded on MAR). 12:00 p.m. and 9:00 p.m. -- [DATE] at 5:00 a.m. (Not recorded on MAR), and 10:30 p.m.( Not recorded on MAR) -- [DATE] at 10:30 a.m. and 5:30 p.m. -- [DATE] at 5:30 a.m., 5:00 p.m. (Not recorded on MAR)., and 11:00 p.m.( Not recorded on MAR) -- [DATE] at 4:30 a.m., and 5:30 p.m. ( Not recorded on MAR) -- [DATE] at 5:00 a.m., 2:00 p.m., and 9:00 p.m. -- [DATE] at 9:00 a.m., 2:25 p.m. and 9:00 p.m. -- [DATE] at 9:00 a.m. (Not recorded on MAR), and 9:00 p.m. (Not recorded on MAR) -- [DATE] at 9:00 a.m., 3:00 p.m. and 10:30 p.m. (Not recorded on MAR) -- [DATE] at 4:40 a.m. Review of the facility's pain management policy on [DATE] at 9:15 p.m. found it included, Pain documentation - All residents will be asked/observed for the presence of pain a minimum of daily. This is documented on the Medication Administration Record (MAR) and/or Point of Care (P[NAME]). Use of medications will be documented on the resident MAR/P[NAME]. Documentation will include: Date/time of resident's pain. Pain rating prior to intervention(s) utilizing the appropriate pain scale. Non-pharmacological utilized, as indicated. Pain rating after intervention utilizing the appropriate pain scale. Monitoring for side effects. Nurse signature/initials . Any resident with persistent pain control issues will have their medical record presented to the physician for review for additional recommendations. In an interview on [DATE] at 10:05 a.m., the Director of Nursing (DON) was told of the multiple documented occasions from [DATE] through [DATE], when the resident refused [MEDICAL TREATMENT] treatments; that according to the resident, she was refusing [MEDICAL TREATMENT] due to pain caused by the wound vac. The lack of evidence of notification of the attending physician and/or nurse practitioner was brought to the DON's attention. Additionally, the DON was informed the [MEDICAL TREATMENT] center had sent recommendations to discontinue the [MEDICATION NAME] on two (2) occasions, [DATE] and [DATE], which the facility had not addressed. As of [DATE], the resident continued to receive the medication and the physician had not been notified of the [MEDICAL TREATMENT] center's recommendations. Review of Resident #170's [MEDICAL TREATMENT] Communication Records found a recommendation from the [MEDICAL TREATMENT] center on [DATE] for, Discontinue [MEDICATION NAME] per (Name of local [MEDICAL TREATMENT] clinic's medical director). Again, on [DATE] the [MEDICAL TREATMENT] clinical sent another recommendation which read, Discontinue [MEDICATION NAME] per (name of local [MEDICAL TREATMENT] clinic's medical director). Review of Resident #170's MARs for the months of ,[DATE] and ,[DATE] found the resident had received [MEDICATION NAME] daily since [DATE]. The record contained no evidence this recommendation from the [MEDICAL TREATMENT] clinic had been communicated to the attending physician. There was no evidence to suggest this recommendation had been acted upon. Corporate Nurse Registered Nurse (CNRN) #277 provided a computer printout of what she stated were pre and post administration pain assessments for Resident #170's as needed pain medication at approximately 2:05 p.m. on [DATE]. Review of the computer printout found the times on the computer printout did not correlate with the actual times the medication was administered. When asked why the times did not match, she stated she would have to get back with the surveyor as to why the times did not match. As of the time exit on [DATE], she had provided no additional information or explanation. b) Resident #225 Medical record review on [DATE] at 1:30 p.m., found this [AGE] year-old resident had [DIAGNOSES REDACTED]. disorder, depression, mood disorder, post-traumatic stress disorder, and [MEDICAL CONDITION] other than [MEDICAL CONDITIONS] of the right knee. He currently receives hospices services for the [DIAGNOSES REDACTED]. Daily medications included: --[MEDICATION NAME] (an antianxiety medication) 11 milligram (mg) 3 times daily; --[MEDICATION NAME] (antipsychotic medication) 25 mg daily at bedtime; and --[MEDICATION NAME] (an antidepressant medication) 15 mg daily at bedtime. --Additionally, he had a pain medication, [MEDICATION NAME]-[MEDICATION NAME] 7XXX,[DATE] milligrams (mg), 1 every 6 hours as needed (prn) for pain. Review of the medication administration record (MAR) found nursing staff administered the [MEDICATION NAME] 20 times thus far in September. Of that total, nursing staff did not assess the effectiveness of the pain medication on seven (7) occasions; did not assess the severity of the pain or show evidence of trying non-pharmacological methods prior to administering the pain medication on seven (7) occasions; and did not note the location of the resident's pain on those seven (7) occasions. The dates and times as described above, were as follows: --[DATE] at 9:00 a.m. (No documentation of pain effectiveness) --[DATE] at 10:00 p.m. (No documentation of pain effectiveness) --[DATE] at 1:35 p.m. (No documentation of pain effectiveness) --[DATE] at 8:00 p.m. (Nursing documented at 3:19 a.m. that the resident had no pain at this time.) --[DATE] at 8:00 p.m. (Nursing documented at 11:10 p.m. that the resident had no pain at this time.) --[DATE] at 8:00 p.m. (Nursing documented at 11:20 p.m. that the resident had no pain at this time.) --[DATE] at 9:00 p.m. (Nursing documented at 12:14 a.m. on [DATE] that the resident had no pain at this time. During an interview at 5:45 p.m. on [DATE], the director of nursing (DON) reviewed the resident ' s MAR, the nurses ' progress notes, and a computer printout where nursing documented times and dates of pain assessments. The DON said there was no place provided on the back of the MARs to note the location, pain severity level, time of pain med administration, and the follow-up pain assessment afterward. The DON said their computer system did not prompt nurses to return to the resident to assess the pain level severity following the administration of pain medication. She agreed there was no evidence on the 7 identified dates and times of the location of the resident's pain, the severity level of the patient's pain prior to medicating, of any non-pharmacological methods employed prior to administering the pain medication, and no timely assessment of the effectiveness of the pain medication. The DON theorized that the reason why the nurses did not document the extent of the relief of the pain until so many hours later was that it took them that long to sit down at their computers and document.",2020-04-01
3903,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,441,E,0,1,0MB311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and infection control surveillance record review, the facility failed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. The infection control surveillance records did not contain needed information. One (1) randomly observed resident's Continuous Passive Motion (CPM) machine was stored directly on an unclean surface, and one randomly observed staff member did not use proper hand hygiene. These practices had the potential to affect more than an isolated number of residents. Resident identifiers: #389, #1001, and #1002. Employee identifier: #128. Facility census: 178. Findings include: a) Infection Control Program On 09/21/16 at 8:14 a.m., an interview with Infection Control Nurse (ICN) #140 who was responsible for the Station 2 side of the facility, revealed there had been a change in the infection control log form the facility used. When asked how and where she tracked the antibiotics used, ICN #140 appeared surprised, paused and said, I guess we don't have to anymore, it's not on the form. The Infection Control Nurse went on to say, We use to track antibiotic names, now just whether the resident is on IV (Intravenous) antibiotic or by mouth. Review of Station 1's infection control book on 09/21/16 at 8:48 a.m., revealed incomplete tracking on the (MONTH) (YEAR) Infection Control Log. On line #10 (Resident #1001) in the column where the organism should have been listed an antibiotic ([MEDICATION NAME]) was listed with no reference to the organism. On line #11 (Resident #1002) the column where the organism should have been listed an antibiotic ([MEDICATION NAME] and Vanc) was listed with no reference to the organism. An interview with Corporate Registered Nurse (RN) #170, on 09/22/16 at 9:21 a.m., verified it was important to know the antibiotics used and the organisms when reviewing the entire infection control program. Corporate RN #270 said, We may have to rethink listing the antibiotic back on the tracking sheet. b) Resident #389 A random observation on 09/19/16 at 11:43 a.m., found a continuous passive motion (CPM) machine on the floor between the resident's bed and the window. It was not sitting on any type of barrier, rather, it was sitting directly on the floor. During an interview with Resident #389 at this time, he said the CPM machine has been placed on the floor every day this past week. Intermittent observations the following two (2) days found it was either on his bed, or on a chair in his room when not in use. During a second interview on 09/22/16 at 8:45 a.m., Resident #389 said the CPM machine had been on the chair in his room whenever it was not in use ever since he told nursing staff Monday (09/19/16) that the surveyor complained about it being on the floor. During an interview on 09/22/16 at 8:50 a.m., Registered Nurse Supervisor #66, She said they usually put residents with knee surgery in a private room and the CPM machine could be placed on the extra bed in the room. She said she could not believe a staff person would put the CPM machine on the floor because it would be in the way there, as well as getting dirty. Review of the resident's medical record on 09/22/16 at 8:55 a.m., found Resident #389 came to the facility on [DATE] after a total knee arthrotomy. On 09/22/16 at 9:15 a.m., during an interview with the director of nursing (DON), she said the CPM machine should not be placed on the floor at any time. c) Licensed Practical Nurse (LPN) #128 On 09/21/16 at 8:15 a.m., LPN #128 washed her hands at the sink in Resident #38's room after she administered the resident's medications. Observation of her handwashing technique found that after she washed her hands and dried them with a paper towel, she then disposed of the paper towel in the trash can. She then used her bare hands to touch the faucet and turn off the water, thereby contaminating her clean hands. Without further hand sanitation, she then proceeded to the cart to pour medications for the next resident. During an interview with the director of nursing (DON) on 09/22/16 at 9:15 a.m., she agreed that staff did not follow the facility's handwashing protocol when she turned off the faucet with her freshly washed hands.",2020-04-01
3904,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,505,D,0,1,0MB311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to promptly notify Resident #179's attending physician of the results of a basic metabolic panel (BMP) which was ordered on [DATE]. This was true for one (1) of four (4) residents reviewed for the care area of nutrition during the Quality Indicator Survey (QIS). Resident Identifier: #179. Census: 178. Findings include: a) Resident #179 A review of Resident #179's medical record at 2:43 p.m. on 09/20/16 found a physician's orders [REDACTED]. Upon further review of the record, the results of the BMP could not be located, nor was there any evidence the attending physician was ever notified of the results of the BMP. At 9:49 a.m. on 09/21/16, the results of the BMP and any information related to the notification of the attending physician were requested from the Assistant Director of Nursing (ADON) Registered Nurse (RN) #140. She stated that she would have to go to medical records and look for the information because she did not see it in the chart. An additional interview with ADON #140 at 11:02 p.m. on 09/21/16, revealed the lab result was not in the record and there was no information available to indicate the attending physician was ever notified of the lab results. She indicated the process was that the Nurse Practitioner or the Attending Physician would sign the lab and there would not be any notes or orders if they did not order any changes. She said that since she could not find the lab results she could not prove the attending physician was ever notified. These findings were reviewed with the Director of Nursing at 2:12 p.m. on 09/21/16 and as of the time of exit on 09/23/16, no additional information was provided.",2020-04-01
3905,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,507,D,0,1,0MB311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain all laboratory (lab) testing results in the resident's clinical record for one (1) of four (4) residents reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey (QIS) and one (1) of three (3) residents reviewed for the care area of hospitalization during Stage 2 of the QIS. Resident #179's record did not contain the results of a Basic Metabolic Panel (BMP) which was ordered to be done on 09/12/16. Resident #151's medical record did not contain the results of a Comprehensive Metabolic Panel (CMP) and a magnesium level obtained on 09/13/16. Resident Identifiers: #151 and #179. Facility Census: 178. Findings Include: a) Resident #151 A review of Resident #151's medical record at 11:16 a.m. on 09/21/16 found a physician's orders [REDACTED]. Upon further review of the medical record, the results of the CMP and magnesium level could not be located. There was however, a nursing progress note dated 09/13/16 which indicated the lab results were reviewed by the Nurse Practitioner with new orders noted. Upon further review of the physician's orders [REDACTED]. During an interview with Assistant Director of Nursing (ADON) Registered Nurse (RN) #140 at 3:09 p.m. on 09/21/16, the results of the CMP and magnesium level were requested. She indicated that she would have to look for them. At 4:26 p.m. on 09/21/16, the Director of Nursing (DON) confirmed they could not locate the requested lab results and had to have a copy faxed to the facility after the surveyor requested them. b) Resident #179 A review of Resident #179's medical record at 2:43 p.m. on 09/20/16 found a physician's orders [REDACTED]. Upon further review of the resident's record, the results of the BMP could not be located. At 9:49 a.m. on 09/21/16 the results of the BMP were requested from the Assistant Director of Nursing ADON - RN #140. She stated that she would have to go to medical records and look for the them because she did not see them in the chart. An additional interview with the ADON RN #140 at 11:02 p.m. on 09/21/16, revealed the lab result was not in the record and after the surveyor had requested she had them faxed from the lab.",2020-04-01
5098,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-03-31,156,E,1,0,LC2M11,"> Based on medical record reviews and staff interviews, the facility failed to ensure each resident had access to updated written information regarding how to contact the certification agency. The Transfer or Discharge Notice had the incorrect address for the certification agency for Residents #20, #26, #59, #109 and #165. This had the potential to affect more than an isolated number of residents. Resident identifiers: Resident #20, #26, #59, #109 and #165. Facility census: 162. Findings include: a) On 03/31/16 at 8:35 a.m., during a review of the Transfer or Discharge Notices for Residents #20, #26, #59, #109 and #165, it was discovered the address for the certification agency was incorrect. The written information provided on the notice regarding the appeal information had not been updated to reflect the correct address for the certification agency. This written information is required to fulfill the facility's obligation to adequately inform residents of their appeal process regarding discharge and transfer. An interview with the Medical Records Clerk, on 03/31/16 at 8:58 a.m., verified the Notice of Transfer or Discharge had the incorrect address for the certification agency for Residents #20, #26, #59, #109 and #169.",2019-03-01
5229,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,156,B,0,1,76WG11,"Based on observation, staff interview, and resident interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits, or how to contact the State Ombudsman. The facility did not prominently display the written information regarding these benefits or the Ombudsman contact information. This had the potential to affect more than an isolated number of residents. Facility census: 160 Findings include: a) On 07/22/15 at 1:35 p.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform residents or responsible parties about how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. An interview with the Nursing Home Administrator on 07/22/15 at 3:07 p.m., revealed she was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits. b) Ombudsman Information On 07/20/15 at 1:00 p.m., during an interview with the resident council president, the president did not know if the facility had the Ombudsman contact information posted. At 1:20 p.m. on 07/20/15, Director of Nursing #205 and Assistant Administrator #235 toured the facility and confirmed the facility did not have the Ombudsman contact information posted.",2019-02-01
5230,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,167,B,0,1,76WG11,"Based on observation and staff interview, the facility failed to ensure a notice of the results of the most recent survey and any plans of correction were in a place readily accessible to residents. The survey results book was located on the wall at a height not accessible to residents in wheelchairs. This practice had the potential to affect more than an isolated number of residents. Facility census: 160. Findings include: a) An observation on 07/22/15 at 1:35 p.m., revealed the survey results book was located in a plastic holder that hung against a wall in the front lobby. The book was too high for residents in a wheelchair to reach. On 07/22/15 at 3:07 p.m., the Nursing Home Administrator agreed the survey book was not located at a height accessible to a resident in a wheelchair. She stated the survey book would be moved to a location accessible to residents in wheelchairs.",2019-02-01
5231,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,225,D,0,1,76WG11,"Based on resident interview, staff interview, and medical record review, the facility failed to ensure allegations of verbal and physical abuse were thoroughly investigated. Resident #163 made an allegation of neglect by a nurse aide. The facility did not thoroughly investigate the resident's allegation before a conclusion was reached that the allegation did not occur. This was found for one (1) of nine (9) reportable abuse/neglect allegations reviewed. Resident identifier: #163. Facility census: 160. Findings include: a) Resident #163 During the Quality Indicator Survey (QIS), Stage 1 interview, on 07/20/15 at 3:24 p.m., Resident #163 reported Nurse Aide (NA) #137 spoke to her harshly on several occasions. Resident #163 reported while NA #137 was assisting her with care, she (resident) fell and hit her head causing both eyes to become black. After the fall, NA #137 stated, You have got to learn to help yourself. Resident #163 continued to explain that on one occasion, she was having trouble having a bowel movement. NA #137 used a washcloth and said in a harsh manner, You are still having a bowel movement. On another occasion Resident #163 reported, NA #137 said in a harsh manner, Try to help yourself, and the nurse aide got hold of me by both shoulders and shook me. During other care, Resident #163 indicated NA #137 said, Why didn't you tell me while you were standing up, and when the resident could not hear the nurse aide said, Why don't you buy some new ones? This was in reference to hearing aids. During the Stage 1 interview at 3:29 p.m. on 07/20/15, NA #137 knocked on the resident's door, opened it, took a slight step into the room and asked the resident Are you ok honey, the resident answered, Yes, and NA #137 stepped out of the room. Resident #163 then stated, That is her, and went on to state, See, she was real nice, you was sitting here. On 07/22/15 at 10:45 a.m., review of the resident's medical record found the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 05/25/15, identified the resident scored 14 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact (the highest possible score is 15). Continued review of the facility neglect/abuse reportable files revealed an incident report made to the facility staff on 07/16/15 by Resident #163's son. The allegation was that NA #137 was speaking rude/harsh to Resident #163 and was handling the resident roughly. Further review of the facility reportable investigation packet revealed a statement by NA#137 dated 07/17/15. (Typed as written) I put (resident) on the bedside & she voided and was pooping she was getting up & wiping while still pooping I sit her back down & told her to wait until she finished before wiping. put my hands over hers on her legs and told her she was not going to be clean from wiping until she was finished so try to finish before wiping. The reportable file also revealed an additional statement, dated 07/17/15, made by Certified Occupational Therapy Assistant (COTA) #5, in which the resident confided the following; I had a rough night yesterday. Resident #163 went on to state, referring to NA #137, (typed as written) .was rough with me, she shook my arms and told me that I don't listen. She was upset because I had to use the bathroom three times. After I started crying she started petting me and I didn't want that. Resident #163 went on to state, I don't want to get anyone in trouble. According to the statement, this occurred around 9:00 p.m. on 07/16/15. Continued review of the neglect/abuse reportable incidents related to Resident #163 revealed NA #137 was placed on leave until further investigation. The reportable file revealed no additional interview/investigation notes until 07/20/15 (time not noted) in which Registered Nurse (RN) #119 interviewed Resident #163. (Typed as written) Interview with (Resident #163) this date regarding son allegation of CNA (nurse aide) being rude, harsh and rough. Resident #163 denies the allegation and states that no one has been rude, harsh or rough with her. She states that there are some that are in too big of a hurry but none have been rude or harsh or rough with her. When asked specifically about (Nurse Aide #137), the resident states that CNA 'has a brash tone but means no harm' States, 'I don't have any problems with anyone but my son is very protective of his Mommy and he tends to over react some. ''' At 5:07 p.m. on 07/20/15, the abuse allegation reported by Resident #163 was reported to the facility administrator, who immediately called RN #119 into the interview. The administrator and Registered Nurse #119 were both aware of the reportable allegation dated 07/16/15 concerning Resident #163 and stated Nurse Aide #137 was placed on leave during the investigation. They also stated they were not aware of all areas reported by the resident during the Stage 1 interview and would immediately open an additional investigation, and place NA #137 on leave again until a further investigation could be completed into the allegations revealed during the Stage 1 interview. In regards to the 07/16/15 allegation, Registered Nurse #119 stated she interviewed Resident #163 in the rehabilitation room during the morning on 07/20/15 and after interviewing the resident, failed to substantiate the allegation of abuse. Registered Nurse #119 indicated she allowed NA #137 to return to work, during the evening shift, on 07/20/15. The reportable file revealed no evidence Resident #163 was interviewed other than in the rehabilitation room the morning of 07/20/15. The file also did not indicate the facility interviewed any other residents who were provided care by NA #137. Other staff members who worked on the same shift and/or hall as NA#137 were also not interviewed. On 07/23/15 at 1:59 p.m., Administrator #126 stated Assistant Administrator (AA) #235 interviewed Resident #163 and received the same information the resident had reported during the Stage 1 interview on 07/20/15. Administrator #126 and AA #235 both agreed RN #119 had not completed a thorough investigation into the allegations made by Resident #163 on 07/16/15.",2019-02-01
5232,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,253,E,0,1,76WG11,"Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services in order to provide a sanitary, orderly and comfortable interior for five (5) of thirty-nine (39) rooms observed during Stage 1 of the survey. Rooms B1, B11, and ESC1 had damaged chair railing behind their beds. Room B4 had chipped Formica on the sink top. A random observation during Stage 2 of he survey revealed Resident #169 had a dirty scoot chair with a cracked armrest. This had the potential to affect more than an isolated number of residents. Room Identifiers: B1, B4, B11 and ESC1. Resident identifier: #169. Facility census: 160. Findings include: a) Room and Furnishing Imperfections -- Observation of Room B1 on 07/20/15 at 3:48 p.m., revealed the wall and chair railing behind the bed was damaged with deep gouaches, scratches, scuffs and missing paint. -- Observation of Room B11 on 07/21/15 at 3:48 p.m., found loose and damaged chair railing behind the bed. -- Observation of Room 4 on 07/21/15 at 10:14 a.m., found there were missing pieces of Formica on the front of the sink top. -- Observation of ESC1 on 07/20/15 at 2:35 p.m., found paint peeling off the chair railing behind the bed. b) Tour with Maintenance Supervisor A tour with the Maintenance Supervisor, beginning at 10:20 a.m. on 07/24/15, confirmed the presence of the room and furnishing imperfections on B and E wings. He agreed the unpainted, loose and damaged chair railing and the missing Formica on the sink front all needed to be repaired and repainted. c) Resident #169 An observation of Resident #169, on 07/23/15 at 10:45 a.m., revealed the resident was sitting in a scoot chair. The seat had a white substance on it. At 10:46 a.m. on 07/23/15, Licensed Practical Nurse (LPN) #218 was informed of the resident's dirty chair. The LPN made an observation of the resident in the scoot chair, and agreed the chair was dirty. At 11:00 a.m. on 07/23/15, the resident remained seated in the hallway in the dirty scoot chair. At 11:35 a.m. on 07/23/15, Resident #169 was in the dining room waiting for lunch. She remained seated in the dirty scoot chair. At 11:40 a.m. on 07/23/15, Assistant Director of Nursing #109 was informed Resident #169 was brought to the dining room seated in a dirty scoot chair. At 11:45 a.m., an observation of Resident #169 revealed she was sitting in the hallway in her scoot chair. The chair was still dirty. At 1:00 p.m. on 07/23/15, another observation revealed the resident was still seated in the dirty scoot chair. LPN #218 looked at the seat of the chair and said it looked like part of the seat had been partially cleaned, but part of it was still dirty. She said she would make sure it was thoroughly cleaned.",2019-02-01
5233,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,312,E,0,1,76WG11,"Based on observation and staff interview, the facility failed to provide the necessary care and services to maintain good personal hygiene for two (2) of three (3) residents reviewed for activities of daily living in Stage 2 of the Quality Indicator Survey. Resident #16's nails were observed dirty on three (3) occasions. Resident #169 had soiled clothing that was not changed for an extended period of time. Resident identifiers: #16 and #169. Facility census: 160. Findings include: a) Resident #16 An observation on 07/20/15 at 2:46 p.m., found Resident #16 had a brown substance under his fingernails. A second observation, on 07/21/15 at 9:30 a.m., again revealed Resident #16 had dirty nails. A third observation on 07/23/15 at 8:41 a.m., with Nurse Aide (NA) #95, confirmed Resident #16's nails were dirty and had a thick brown substance under the nails. The NA related his nails should have been cleaned. During an interview with NA #244, on 07/23/15 at 9:59 a.m., the nurse aide related the resident sometimes attempted to toilet himself, and would get bowel movement under his nails, and indicated fingernails should be cleaned daily. Licensed Practical Nurse (LPN) #218 confirmed during an interview, on 07/23/15 at 8:34 a.m., that residents' fingernails should be checked daily, and cleaned if dirty. b) Resident #169 An observation of Resident #169 on 07/23/15 at 10:35 a.m., revealed she was sitting in a scoot chair with a dirty seat in the hallway next to her room. She was holding a cup of ice cream, some of which had fallen onto her pants, soiling them near the thigh area. At 10:45 a.m., LPN #218 observed Resident #169. She agreed the resident's chair was dirty, but did not mention the soiled pants. At 11:00 a.m. on 07/23/15, Resident #169 remained seated in the hallway in a dirty scoot chair and soiled pants. At 11:35 a.m., Resident #169 was observed in the dining room, getting ready to eat lunch, in the same soiled pants and dirty chair. The resident's soiled pants was brought to the attention of Activity Director (AD) #105 on 07/23/15 at 11:35 a.m. AD #105 said she would ensure the resident's pants were changed. At 11:40 a.m. on 07/23/15, Assistant Director of Nursing #109 was informed Resident #169 had been brought to the dining room wearing dirty pants and was seated in a dirty scoot chair. A review of the quarterly minimum data set (MDS), with an assessment reference date of 05/10/15, reflected Resident #169 needed extensive assistance with the support of one (1) person in order to complete the dressing task.",2019-02-01
5234,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,315,D,0,1,76WG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and medical record review, the facility did not ensure a resident who was incontinent of bladder received the appropriate care and services to prevent urinary tract infections (UTIs) and/or to prevent a decline in the ability to toilet for one (1) of three (3) residents reviewed for urinary incontinence. Resident identifier: #258. Facility census: 160. Findings include: a) Resident #258 On 07/23/15 at 1:59 p.m. review of the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 03/16/15, revealed Resident #258 had at least one (1) continent episode in the seven (7) day look-back period. The most recent MDS, with an ARD of 06/12/15, revealed the resident was always incontinent (no episodes of continent voiding), which indicated a decline in continence. 1. On 07/23/15 at 2:23 p.m., the care plan review indicated Resident #258 had a history of [REDACTED]. During an observation of incontinence care, performed by Nurse Aide (NA) #236 on 07/23/15 at 2:39 p.m., the NA entered the room. Without first washing her hands, she donned gloves. The NA obtained a container of wipes, which she placed on the bedside. The NA unfastened Resident #258's brief, obtained a wipe and washed each side of the groin area. The NA then positioned the resident on her left side. The resident had experienced a bowel movement. NA #236 cleaned the stool from Resident #258's buttocks and rectum. Without changing gloves, the NA cleansed the urethral area and outer labia toward the perineum. Upon completion of incontinence care, NA #236 repositioned Resident #258 and placed the wipes in the resident's dresser. The NA placed the soiled brief in a garbage bag and removed the glove from her right hand. The NA tied the bag, then removed the glove from her left hand. Without sanitizing her hands, NA #236 carried the garbage to the soiled linen room. The NA then returned to Resident #258's room and washed her hands. The facility's clinical validation for perineal care and standards of practice tool, reviewed on 07/23/15, at approximately 3:45 p.m., indicated staff would wash hands, and don gloves. If present, remove feces, change gloves, provide perineal care, remove gloves and wash hands, adjust clothing and wash hands again then remove any soiled items. An interview with Nurse Aide (NA) #27 on 07/23/15 at 3:14 p.m., revealed Resident #258 was totally incontinent. Upon inquiry, the NA related staff did not complete voiding diaries to evaluate a resident's continence patterns. The NA indicated the nurse reported the resident's history, such as if the NA needed to use a bedpan or urinal, or how to care for a resident. Review of the urinary incontinence/indwelling catheter - assessment and management policy, on 07/23/15, at approximately 3:45 p.m., revealed, the facility would assess for urinary incontinence on admission and change in condition. The policy further stated the facility would (typed as written) complete a voiding diary over several day to help determine the resident's pattern and type of incontinence . The evaluation would also include a review for potentially transient causes that might affect continence and address those issues. On 07/23/15 at 4:15 p.m., the director of nursing (DON) confirmed the facility had not completed a voiding diary to determine Resident #258's voiding pattern. The DON confirmed staff had not utilized proper technique during incontinence and perineal care to prevent urinary tract infections. 2. The care plan review, on 07/23/15 at 2:23 p.m., also revealed Resident #258 required assistance with activities of daily living (ADLs) due to decreased functional mobility, weakness, impaired balance, and cognitive status related to dementia, recent hospitalization , [MEDICAL CONDITION], and self-care deficit. The care plan indicated the resident required total assistance with toileting. Physical Therapy Assistant (PTA) #2, on 07/23/15 at 2:54 p.m., indicated Resident #258 refused to participate with therapy. PTA #2 said, upon return from a hospital stay, the resident was only picked up for speech therapy (ST). Review of occupational therapy notes, dated 11/16/14 through 02/15/15, indicated Resident #258 demonstrates good rehab (rehabilitation) potential as evidenced by supportive caregivers/staff . Rehabilitation Director #4, interviewed on 07/23/15 at 3:00 p.m., related Resident #258 had made minimal progress in hygiene and grooming, but was discharged from therapy because she was transferred to the hospital. The medical record, reviewed on 07/23/15 at 3:30 p.m., revealed no indication Resident #258 received therapy, or had a therapy screen from 02/15/15 to present. Physical and occupational therapy records were not available in the medical record. When interviewed on 07/23/15 at 4:15 p.m., the DON confirmed the facility had not ensured Resident #258 was screened by therapy to determine whether she would benefit from therapy related to toileting.",2019-02-01
5235,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,325,D,0,1,76WG11,"Based on record review and staff interview, the facility failed to provide services to assist one (1) of three (3) residents, reviewed for the care area of nutrition, in maintaining acceptable parameters of nutritional status. The resident's weight was on a downward trend. The registered dietitian (RD) recommended daily snacks which were not implemented by the facility. Resident identifier: #169. Facility census: 160. Findings include: a) Resident #169 The medical record review, on 07/20/15 at 10:00 a.m., revealed the resident's quarterly minimum data set (MDS) assessment, with an assessment reference date of 05/22/14, indicated Resident #169 weighed 134 pounds (lbs). The annual MDS, with an ARD of 08/20/14, indicated the resident had lost 5 lbs, and was down to 128 lbs. According to weight records, the resident weighed 119 lbs on 01/02/15, which was 10 lbs less than the assessment with the ARD of 08/20/14. On 04/18/15 and 07/02/15, the weight records indicated a loss of another five (5) pounds, down to 114 lbs. A nutritional assessment, dated 05/19/15, identified the resident had a weight loss trend. According to the medical record, the resident was not receiving a nutritional supplement. As of the date of the review, on 07/20/15, the medical record reflected the resident's height was 61 inches and her weight was 114 lbs. On 07/22/15 at 9:58 a.m., Resident #169 said she had eaten eggs and bacon for breakfast. Licensed Practical Nurse (LPN) #218 was interviewed at 10:00 a.m. on 07/22/15. After reviewing the resident's medical record, the LPN said the resident's dinner consumption for the evening meal on 07/21/15 was not documented. She also commented that the resident's weight had fluctuated since (MONTH) with gains and losses. LPN #218 said, We will look at this resident for a supplement and I will check with the dietitian. On 07/22/15 at 10:30 a.m., an interview with Dietitian #30 revealed the resident had the following weights recorded in the medical record for (YEAR): -- 01/02/15 119 lbs. -- 02/09/15 115 lbs. -- 03/16/15 116 lbs. -- 04/08/15 114 lbs. -- 05/07/15 118 lbs. -- 06/03/15 112 lbs. -- 06/26/15 115 lbs. -- 07/02/15 114 lbs. Dietitian #30 said the resident was trending down with her weights. She said Resident #169's intakes for the last 14 days had been between 50-75%. The nutritional assessment, completed on 05/15/15 by Dietitian #140 with Dietitian #30 included: QTR (quarter) review. PO (by mouth) intake varies; 0-25% x 3 meals; 26-50 x 1 meal; 51-75 % x 10 meals. No sig. (significant) wt. (weight) change this review. Wt. loss trend x 6 months. BMI (body mass index) WNL (within normal limits) snacks tid (three times a day) no feeding tube. An interview with Dietary Manager (DM) #43, on 07/22/15 at 10:50 a.m., revealed Resident #168 was not on the list to get snacks. Dietitian #30 said she would ensure the recommendation from (MONTH) regarding the snacks three (3) times a day was followed up. Dietitian #30 said this recommendation should have been put on a communication sheet and sent to the assistant director of nursing in (MONTH) when Dietitian #140 made the recommendation. Dietitian #30 said she would ensure this recommendation was followed through. She said she would also ask the resident what kind of snacks she liked. On 07/22/15 at 11:18 a.m., Nurse Aide #33 confirmed Resident #169 did not receive snacks. A progress note written by Dietitian #30 on 07/22/15 at 11:22 a.m., revealed, RD follow-up. Visited w (with)/resident to attempt to obtain preferences for snacks to offer d/t (due to) WT (weight) loss trend. Limited information obtained d/t confusion at time of visit 'I'm losing weight cause I was playing sports.' Will provide diet suggestions for snacks to offer at 10a, 2p, & 8p. Please monitor tolerance/acceptance and notify dietary to allow for adjustments in items offered to encourage tolerance and attempt to increase overall intake to promote WT (weight) stability. Encourage intake of meals & snacks as tolerated. Monitor WT as ordered. Will continue to follow as needed. On 07/23/15 at 8:16 a.m., an interview with DM #43 revealed Dietitian #30 interviewed Resident #169 and made a note for the resident to get snacks. DM #43 said the resident would get yogurt at 8:00 a.m., ice cream at 2:00 p.m., and a whole milk and 1/2 sandwich at 8:00 p.m. She said these snacks would print out on the tickets in the mornings to ensure the resident received the snacks.",2019-02-01
5236,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,329,D,0,1,76WG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of five (5) residents reviewed for unnecessary medications was free from unnecessary medications. Resident #27 received an antipsychotic medication ([MEDICATION NAME]) without adequate indication for its use, The medical director and psychiatrist recommended the medication be discontinued; however, the resident's Medical Power of Attorney (MPOA) did not want the medication discontinued. There was no evidence the MPOA was provided education about the use of the medication. Resident identifier: #27. Facility census: 160. Findings include: a) Resident #27 The medical record review for Resident #27, completed on 07/22/15 at 2:00 p.m., revealed a note from the resident's psychiatrist dated 01/03/15 which stated, I will go ahead and take her off the [MEDICATION NAME] and just leave her on the [MEDICATION NAME], 25 mg (milligram) daily, [MEDICATION NAME], 10 mg daily. We will see how she does. If she has any problems, just let me know. A physician visit note dated 01/03/15 stated, (Psychiatrist name) in facility and new order to d/c (discontinue) [MEDICATION NAME] order noted pharm (pharmacy) faxed and MAR (medication administration) record completed (name of medical power of attorney) aware. A progress note dated 01/15/15 N/O (new order) per (physician name) [MEDICATION NAME] 12.5 mg po at HS. (night) MPOA (medical power of attorney) (name) aware. an order written [REDACTED]. (patient) stable. Another physician's orders [REDACTED]. There was no evidence that the MPOA was provided with information about the risks and benefits of continued use of [MEDICATION NAME] for the resident. Assistant Director of Nursing (ADON) #109 indicated, on 07/22/15 at 2:00 p.m., that the MPOA insisted the resident receive the [MEDICATION NAME]. She was asked what the justification was for putting the resident back on the [MEDICATION NAME] on 01/15/15 after it was discontinued on 01/03/15. She referenced a progress note dated 01/06/15 which stated, Talked to resident's son (name), states 'I didn't leave Mom any money. Mom is confused, I will call her and talk to her.' ADON #109 said this was the only note the facility had that documented the rationale that was used to put the resident back on [MEDICATION NAME] 12.5 mg. The ADON said the medical director needed to discuss this matter further with the MPOA because he was very resistant to any changes in the resident's medication.",2019-02-01
5237,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,371,E,0,1,76WG11,"Based on observation, staff interview, and a review of temperature monitoring logs, the facility failed to ensure food was stored under clean, sanitary conditions. The kitchen milk cooler and snack refrigerators on the units were not clean, sanitary, and/or maintained at the U.S. Food and Drug Administration (FDA) required temperature recommendations to keep foods safe for human consumption. This practice had the potential to affect more than a limited number of residents. Facility census: 160. Findings include: a) Milk Cooler During the initial kitchen tour on 07/20/15 at 11:00 a.m., the milk cooler did not have a thermometer to monitor the temperature. Dietary Manager (DM) #43 stated the milkman delivered milk that morning and must have taken the thermometer again. She stated the thermometer would sometimes fall down inside the milk crates, and sometimes the milkman unknowingly took the thermometer with him. DM #43 replaced the thermometer in the milk cooler. She taped it to the front inside wall. Review of the (MONTH) temperature log for the milk cooler, at 3:45 p.m. on 07/20/15, showed out of 39 opportunities to log thermometer readings, there were three (3) entries left blank; seventeen (17) entries stating no thermometer, and nineteen (19) entries with actual temperature readings logged. There were no temperatures monitored for the milk cooler starting with the evening entry on 07/03/15 until the morning entry on 07/06/15, a total of two and a half (2 1/2) days. There were no temperatures monitored for the milk cooler starting from the morning entry on 07/09/15 until the morning entry on 07/15/15, a total of six (6) days. There were no morning or evening temperatures monitored on 07/17/15. Milk cooler temperatures were also not monitored for the evening of 07/19/15 or the morning of 07/20/15 (a 24 hour period). On 07/22/15 at 11:59 a.m., an interview with DM #43 revealed the milkman delivered milk around 5:00 a.m. three (3) times a week, on Monday, Wednesday, and Friday. The milk cooler temperatures were to be checked two (2) times a day, at beginning of the day shift and in the evening. On the outside of the cooler near the floor, was an exterior thermometer that was difficult to see; however, DM #43 stated staff used the interior thermometer to log temperature readings, not the exterior thermometer. Review of the (MONTH) temperature log for the milk cooler, with the dietary manager, revealed the log was incomplete, rendering the monitoring system ineffective. b) Nurses' Station number one (#1) snack refrigerator On 07/22/15 at 12:16 p.m., an inspection of Nurses' Station number one (#1) food pantry revealed the refrigerator temperature was 44 degrees Fahrenheit (F). This was higher than FDA recommendations of maintaining refrigerated foods at a temperature of no more than 40 degrees F. Registered Nurse #112, verified the refrigerator temperature was 44 degrees F and stated she would get maintenance to check the refrigerator due to .the refrigerator not staying as cold as it should. c) Nurses' Station number two (#2) snack refrigerator Inspection of Nurses' Station number two (#2) food pantry, on 07/22/15 at 12:07 p.m., revealed the refrigerator freezer was dirty. There were multiple individual cups of ice cream tossed haphazardly in the freezer, where the walls and floor of the freezer were covered with multiple splashes of a dried red sticky substance. Interview with Assistant Director of Nursing #109, on 07/23/15 at 3:50 p.m., revealed, . the kitchen staff cleans the refrigerator in Nurses' Station 2 snack room. On 07/23/15 at 3:59 p.m., an interview with DM #43 revealed the nurses were to clean the refrigerators at the nurses' station snack rooms. A copy of the facility's policy was requested, but was not provided. In an interview with Director of Nurses #205, on 07/23/15 at 4:02 p.m., she said kitchen staff was responsible for cleaning the refrigerator in Nurses' Station 2 snack room.",2019-02-01
5238,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,372,E,0,1,76WG11,"Based on observation and staff interview, the facility failed to dispose of garbage and refuse properly. At the dumpster area, eight (8) unbagged used disposable gloves were scattered around the garbage dumpster area, and another used glove was hanging outside the dumpster door. This practice had the potential to affect more than an isolated number of residents. Facility census: 160 Findings include: a) On 07/23/15 at 8:20 a.m., an observation of the outside dumpster area, accompanied by the Dietary Manager (DM) #43, revealed a used disposable glove lying on the sidewalk halfway between the exterior kitchen door and the dumpster. At the dumpster, a used disposable glove was observed caught on, and hanging outside the dumpster door. Seven (7) used soiled disposable gloves were also observed lying scattered on the ground under the dumpster door. DM #43 immediately notified the Maintenance Supervisor (MS) #92 and the used soiled gloves were cleaned up. DM #43 and MS #92 agreed the used soiled gloves should have been bagged and disposed of inside the dumpster.",2019-02-01
5239,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,425,E,0,1,76WG11,"Based on observation, staff interview, review of the Center for Disease Control and Prevention (CDC) guidelines, the facility, in collaboration with the consultant pharmacist, failed to ensure safe and effective pharmacy services to meet the needs of residents on the A, B, C, and D halls. The medications stored in the medication room refrigerator were expired and/or stored past the dates prescribed. Resident identifiers: #277, #243, #218, #35, #185, #25, and #300. Facility census: 160 Findings include: On 07/20/15 at 12:45 p.m., the medication room for halls A, B, C, and D was observed to contain the following medications which should have been discarded. a) Resident #277 Twelve (12) administrations of Zosyn Iso-osmotic 2.25 grams (gm) to be administered intravenously (IV) every six (6) hours for seven (7) days starting 07/11/15. b) Resident #243 Three (3) administrations of Zosyn Iso-osmotic 3.375 gm to be administered IV every six (6) hours for ten (10) days starting 06/26/15. c) Resident #218 One administration of Ceftriaxone one gm to be administered IV every day for seven (7) days with an expiration date of 05/04/15. d) Resident #35 Two administrations of Ceftriaxone one gm to be infused ever day for ten (10) days. The medication was prescribed on 06/06/15 and expired on 06/27/15. e) Resident #185 One administration of Cefepime one gm to be infused IV every 12 hours for seven days with a prescribed date of 05/05/15 and an expiration date of 06/12/16. f) Resident #25 One administration of Ceftriaxone one gm to be infused IV daily for seven days prescribed 07/01/15. g) Resident #300 One administration of Vancomycin oral solution 250 milligrams (mg)/50 millimeters (ml) with an expiration date of 06/08/15. h) On 07/20/15 at 1:07 p.m., Assistant Director of Nursing #109 for halls A, B, C, and D, agreed the medications should have been destroyed prior to the the noted observations. At 2:31 p.m. on 07/23/15, the director of nursing was made aware of these findings and stated medications would be disposed of properly in the future.",2019-02-01
5240,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,441,F,0,1,76WG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to maintain an effective infection control program to prevent the development and transmission of disease and infection to the extent possible. Personal protection equipment (PPE) was not used when indicated. A contaminated nasal oxygen cannula was re-inserted it into the nares of Resident #193. The bases of electronic vital sign machines were visibly soiled. Dirty and clean linens were not transported in a manner to prevent cross contamination. Hand hygiene was not completed when indicated. These practices had the potential to affect all residents. Resident identifiers: #220, #193, #232, #258. Facility census: 160. Findings include: a) Resident #220 On 07/21/15 at 8:50 a.m., Nurse Aide (NA) #232 served a meal tray to Resident #220. She wore no personal protective equipment. Signage posted at the doorway entrance warned of droplet isolation precautions. Upon inquiry as to which resident was in droplet precautions, she said she did not know. She looked at the signage, said Oh, Jesus, washed her hands and left the room. At 8:55 a.m. on 07/21/15, Licensed Practical Nurse #220 said Resident #220 had Methicillin Resistant Staphylococcus Aureus (MRSA) cultured in his sputum. She said all who entered the room must wear a facemask, gloves, and a disposable gown. Observation of the room found no isolation trash receptacle in which to dispose of used gloves, face masks, and disposable gowns. On 07/21/15 at 11:55 a.m. the director of nursing (DON) said there should be a designated trash receptacle for disposable personal protective equipment used when providing care in the room of Resident #220. She also said all staff who entered the room must don personal protective equipment. She said she would immediately obtain a designated isolation trash receptacle for the room. Review of the medical record at that time revealed a 07/06/15 physician's orders [REDACTED]. Review of the medical record on 07/23/15 at 2:00 p.m., found a physician's orders [REDACTED]. On 07/23/15, the physician ordered a [MEDICATION NAME] 1.5 milligrams topically every three (3) days for increased respiratory secretions. b) Resident #193 On 07/20/15 at 3:30 p.m., Nurse Aide #158 was made aware that the resident's nasal oxygen cannula was lying on the floor beside her bed. At that time, Nurse Aide #158 picked up the nasal oxygen cannula and placed it back in the resident's nose. On the afternoon of 07/22/15, Assistant Director of Nursing #109 was made aware of the issue regarding Resident #193. Assistant Director of Nursing #109 said she would do re-education with the employee. c) During Stage 1 of the Quality Indicator Survey (QIS), five (5) portable vital sign towers used for halls A, B, C, and D, were observed visibly soiled on the bottom. Throughout the survey, the vital sign towers remained soiled. On 07/23/15 at 3:16 p.m., Director of Nursing #205 agreed the vital sign towers were soiled and immediately had the towers cleaned. d) Resident #232 and Resident #258 During a random opportunity for observation, on 07/23/15 at 8:05 a.m., Nurse Aide (NA) #33 made the bed for Resident #232. Upon completion, the NA picked up soiled linens from the floor near Resident #258's bed, with her bare hands, and placed them in a black garbage bag. The NA twisted the bag. Hugging it against her uniform, she exited the room without sanitizing her hands. Nurse Aide #33 carried the soiled linens down the hall and deposited them in the soiled linen closet. She then went to the clean linen closet, and without sanitizing her hands, obtained linens and placed them at the foot of Resident # 258's bed. Resident #232 requested assistance, and again without sanitizing her hands, NA #33 assisted Resident #232. Licensed Practical Nurse (LPN) #218 was present during the observation. The LPN confirmed Nurse Aide #33 should have donned gloves prior to picking up the soiled linens from the floor, and should not have held the bag containing soiled linen against her uniform. The nurse also confirmed the nurse aide should have washed her hands prior to exiting the room and prior to opening the door of the linen closet and obtaining clean linens. Review of the linen handling policy noted it was important that all potentially contaminated linen be handled with appropriate measures to prevent cross-contamination . Nursing staff should also be aware of the potential of uniform contamination if dirty linen comes into contact with their clothing. Conversely, nursing staff should not carry clean linen in contact with their clothing. An interview with the DON on 07/23/2015 8:50 a.m., revealed she was aware of the incident, and confirmed Nurse Aide #33 handled linens incorrectly and failed to sanitize her hands when required, creating a potential for cross contamination and spread of disease and infection.",2019-02-01
5241,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,520,E,0,1,76WG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility's Quality Assessment and Assurance (QA&A) committee failed to identify and/or act upon a quality deficiency within the facility's operations of which it did have, or should have had, knowledge related to its infection control program. The facility also failed to implement plans of action to correct these deficiencies, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. This had the potential to affect all residents. Facility census: 160. Findings include: a) Resident #220 On 07/21/15 at 8:50 a.m., Nursing Assistant #232 served a meal tray to Resident #220. She wore no personal protective equipment. Signage posted at the doorway entrance warned of droplet isolation precautions. Upon inquiry as to which resident was in droplet precautions, she said she did not know. She looked at the signage, said Oh, Jesus, washed her hands and left the room. At 8:55 a.m. on 07/21/15, Licensed Practical Nurse (LPN) #220 said Resident #220 had [MEDICAL CONDITION] (MRSA) cultured in his sputum. She said all who entered the room must wear a face mask, gloves, and a disposable gown. Observation of the room found no isolation trash receptacle in which to dispose of used gloves, face masks, and disposable gowns. On 07/21/15 at 11:55 a.m., the director of nursing (DON) said there should be a designated trash receptacle for disposable personal protective equipment used when providing care in the room of Resident #220, and all staff who entered the room must don personal protective equipment. She said she would immediately obtain a designated isolation trash receptacle for the room. Review of the medical record at that time revealed a 07/06/15 physician's orders [REDACTED]. Review of the medical record on 07/23/15 at 2:00 p.m., found a physician's orders [REDACTED]. On 07/23/15 the physician ordered a [MEDICATION NAME] 1.5 milligrams topically every three (3) days for increased respiratory secretions. b) Resident #193 On 07/20/15 at 3:30 p.m. Nurse Aide #158 was made aware that the resident's nasal oxygen cannula was lying on the floor beside her bed. At that time Nurse Aide #158 picked up the nasal oxygen cannula and placed it back in the resident's nose. On the afternoon of 07/22/15 Assistant Director of Nursing #109 was made aware of the issue regarding Resident #193. Assistant Director of Nursing #109 said she would do reeducation with the employee. c) During Stage 1 of the Quality Indicator Survey (QIS) five (5) portable vital sign towers used for halls, A, B, C, and D, were observed visibly soiled on the bottom. Throughout the survey the vital sign towers remained soiled. On 07/23/15 at 3:16 p.m., the director of nursing (DON) agreed the vital sign towers were soiled and immediately had the towers cleaned. d) Linen handling During a random opportunity for observation, on 07/23/15 at 8:05 a.m., Nurse Aide #33 made the bed for Resident #232. Upon completion, the NA picked up soiled linens from the floor near Resident #258's bed with her bare hands and placed them in a black garbage bag. The NA twisted the bag, and hugging it against her uniform, exited the room without sanitizing her hands. Nurse Aide #33 carried the soiled linens down the hall and deposited them in the soiled linen closet. She then went to the clean linen closet, and without sanitizing her hands, obtained linens and placed them at the foot of Resident # 258's bed. Resident #232 requested assistance, and again without sanitizing her hands assisted the resident. Licensed Practical Nurse (LPN) #218 was present during the observation. The LPN confirmed Nurse Aide #33 should have donned gloves prior to picking up the soiled linens from the floor, and should not have held the bag containing soiled linen against her uniform. The nurse also confirmed the nurse aide should have washed her hands prior to exiting the room and prior to opening the door of the linen closet and obtaining clean linens. Review of the linen handling policy noted it was Important that all potentially contaminated linen be handled with appropriate measures to prevent cross-contamination . Nursing staff should also be aware of the potential of uniform contamination if dirty linen comes into contact with their clothing. Conversely, nursing staff should not carry clean linen in contact with their clothing. An interview with the DON on 07/23/15 at 8:50 a.m., revealed she was aware of the incident, and confirmed Nurse Aide #33 handled linens incorrectly and failed to sanitize hands when required, creating a potential for cross contamination and spread of disease and infection. e) During an interview with Administrator #126 and Assistant Administrator #235 on 07/23/15 at 3:40 p.m., they said the facility recently identified similar infection control issues as those identified during the Quality Indicator Survey. In response to their self- identified issues, they developed an action plan whereby the nurse practice educator provided a facility wide infection control inservice in (MONTH) (YEAR) for all employees. Following staff education, the facility utilized a monitoring tool, and unit managers performed daily rounding and audits. The unit managers also did spot checks for isolation rooms to ensure staff used appropriate personal protective equipment (PPE). They explained that for a period of time, they intentionally focused on infection control performance daily, and used the auditing tools for data collection and specific monitoring. Now, infection control surveillance issues remained part of the unit manager's daily routine, although the unit managers no longer audited with a specific tool. The unit managers currently did general rounding, and discussed any new infection control issues that might develop. Since learning of the the Quality Indicator Survey results, they said they plan now to schedule more in-servicing and staff education, and make their spot checks and monitoring much more focused daily. They spoke of plans of expanding the interdisciplinary involvement to not just nurse managers, but also other department heads and other nursing staff members, to correct the issues identified.",2019-02-01
6042,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-03-27,161,E,0,1,R3PM11,"Based on record review and staff interview, the facility failed to guarantee the security of all personal funds deposited with the facility. The facility did not have a surety bond of sufficient value to cover the highest daily balance of the resident trust fund for February 2014. This had the potential to affect all 117 residents with a resident trust fund account. Facility census: 135. Findings include: a) On 03/24/14 at 3:00 p.m., review of the resident funds on deposit found the highest daily balance, according to the Account Summary for February 2014, balance was $69,988.73 on 02/07/14. The facility's current surety bond was for $60,000.00. The bond was insufficient to cover the resident trust fund accounts of the one hundred seventeen (117) residents who had a trust account with the facility. b) On 03/24/14 at 3:30 p.m., an interview was completed with Employee #152 (Business Office Manager), she acknowledged the daily balance on 02/07/14 of $69,988.73 had exceeded the amount of the current surety bond.",2018-05-01
6043,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-03-27,272,D,0,1,R3PM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident's comprehensive assessment accurately reflect the resident's medications, one of the required elements for the comprehensive assessment. Resident #46's comprehensive minimum data set (MDS) assessment did not identify the resident was receiving an antidepressant. This was found for one (1) of nineteen (19) Stage 2 residents. Resident identifier: #46. Facility census: 135. Findings include: a) Resident #46 During record review, on 03/18/14 at 1:30 p.m., it was revealed that Resident #46 had an order dated 01/31/14, for [MEDICATION NAME], an antidepressant, 30 milligrams (mg) orally each day. The last comprehensive assessment, with an assessment reference date (ARD) of 02/06/14, made no reference to the use of the antidepressant ([MEDICATION NAME]). On 03/26/14 at 4:00 p.m., the director of nursing (DON) reviewed the January and February 2014 physician's orders [REDACTED].#46 had a physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The DON verified an antidepressant should have been coded on the MDS, with an ARD of 02/06/14. A correction MDS was completed.",2018-05-01
6044,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-03-27,279,D,0,1,R3PM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop care plans based on assessments of the resident's condition in regard to [DIAGNOSES REDACTED].#46 and urinary incontinence for Resident #234. This was true for two (2) of nineteen (19) Stage 2 residents. Resident identifiers: #46 and #234. Facility census: 135. Findings include: a) Resident #46 A record review, performed on 03/18/14 at 1:30 p.m., found current MEDICATION ORDERS FOR [REDACTED]. On 03/26/14 at 3:30 p.m., review of the resident's care plan found it did not address the resident's needs associated with these conditions. There were no plans developed for the issues associated with diabetes, anxiety, or [MEDICAL CONDITION]. The care plan also did not address the potential adverse effects of the medications used to treat the [DIAGNOSES REDACTED]. At 3:40 p.m. on 03/26/14, this was discussed with the director of nursing who agreed the issues associated with the [DIAGNOSES REDACTED]. b) Resident #234 Medical record review, completed on 03/26/14 at 3:45 p.m., revealed the minimum data set (MDS), with an assessment reference date (ARD) of 12/19/13, reflected the resident was occasionally incontinent. The MDS, with an ARD of 02/12/14 indicated the resident's urinary continence had changed to frequently incontinent. The care plan, developed on 12/19/13 and revised on 02/19/14, did not address urinary continence. The care plan did not provide any interventions to prevent further decline in urinary continence for this resident. In an interview with Employee #75 (registered nurse/assessment coordinator), on 03/26/14 at 5:25 p.m., she verified bladder incontinence had not been addressed on the current care plan.",2018-05-01
6045,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-03-27,309,D,0,1,R3PM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the necessary care and services to attain or maintain the highest practicable physical well-being for one (1) of three (3) Stage 2 residents reviewed for hospitalization after admission. The facility failed to obtain physician ordered laboratory work required to monitor the resident's use of antocoagulant medication. The resident subsequently required hospitalization due to [MEDICAL CONDITION] of the left lower extremity. Resident identifier: #31. Facility census: 135. Findings include: a) Resident #31 A review of the medical record, on 03/24/14 at 4:00 p.m., revealed this [AGE] year old resident was admitted to the facility on [DATE] from an acute care hospital. The hospital's admission history and physical (H&P), dated 12/06/13, revealed Resident #31 had slight weakness on the left side, and a possible [MEDICAL CONDITION]. The resident also had chronic venous stasis and [MEDICAL CONDITION] of her left lower extremity. The H&P also noted the resident was on [MEDICATION NAME] with a therapeutic INR. The INR result was 2.89 on 12/06/14. (PT/INR ([MEDICATION NAME] time and international normalized ratio) is a lab test used to monitor bleeding and clotting time for those who are on anticoagulation therapy, such as with [MEDICATION NAME]. The therapeutic range of the INR is between 2.0 and 3.0.) The hospital's discharge summary, dated 12/10/14, indicated the primary [DIAGNOSES REDACTED]. Another discharge [DIAGNOSES REDACTED]. A PT/INR at the hospital on [DATE] showed an INR value of 1.69. Initial physician's orders [REDACTED]. A registered nurse completed a situation background assessment recommendation (SBAR) on 12/29/14 at 1:45 p.m. The nurse stated (typed as written) Resident d/t (due to) have PT/INR on 12/17/13. Lab slip not filled out and lab was not drawn. Resident on ATB (antibiotic) therapy. She notified the physician who then gave orders for an immediate PT/INR. The INR was 1.08. The physician increased the daily dose of [MEDICATION NAME] to 5 mg daily, and ordered a repeat PT/INR on 01/01/14. On 01/01/14 the INR was only 1.19. The physician increased the daily dose of [MEDICATION NAME] to 6 mg daily, and ordered a repeat PT/INR on 01/03/14. The INR was 1.32 on 01/03/14. The physician increased the daily dose of [MEDICATION NAME] to 6.5 mg. daily, and ordered a repeat PT/INR on 01/06/14. Review of nursing notes, dated 01/04/14 at 10:25 p.m., found a change in the resident's condition. Registered nurse Employee #69 assessed a discoloration to the resident's left lower extremity (LLE). The LLE was (typed as written) blue in color from ankle to just below knee, foot was of normal color, pedal pulse was faint, pt (patient) did have +3 [MEDICAL CONDITION] present. (The doctor) was notified of findings. The resident was transported to the local hospital by emergency medical services. The resident was admitted to the hospital for a [MEDICAL CONDITION] of the LLE. She returned to the facility on [DATE]. The INR on the day of discharge from the acute care facility was 2.34.",2018-05-01
6046,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-03-27,332,D,0,1,R3PM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, pharmacist interview, review of Centers for Medicare Services (CMS) guidance to surveyors, information from the Federal Drug Administration (FDA), and information from the National Institutes of Health (NIH), the facility failed to ensure it was free of a medication error rate of five (5) percent or greater. The facility had a medication error rate of 5%. Resident #11 received antibiotic eye drops without sufficient contact time allowed between drops. Resident #114 was not instructed to rinse her mouth after receiving an inhaler. Two (2) of nine (9) residents were affected. Resident identifiers: #11 and #114. Facility census: 135. Findings include: a) Observation of medication administration pass, on 03/17/14 at 4:00 p.m., 03/19/14 at 8:00 a.m., and 03/20/14 at 7:00 a.m., identified 36 opportunities for medication errors. There were two (2) medication errors observed in the thirty-six (36) opportunities for error. b) Resident #11 On 03/17/14 at 4:10 p.m. a licensed nurse Employee #2 was observed as she administered two (2) drops of an antibiotic eye medication ([MEDICATION NAME]) into each of Resident #11's eyes. She administered the drops in quick succession, with only a few seconds between each instilled eye drop. An interview was conducted with the director of nursing (DON) on 03/25/14 at 12:20 p.m. She said there should be a timed interval between a first and a second dose of an eye drop. She said the drops were not to be given in quick succession, although she was unsure of the exact time interval involved. Later, at 3:10 p.m., she said she was unable to find a policy regarding how close to space two (2) eye drops if they were the same medication. The pharmacist was interviewed on 03/25/14 at 12:30 p.m. He provided his pharmacy's policy guideline related to instillation of eye drops. His interpretation of the guideline was that three (3) to five (5) minutes must elapse between each eye drop instilled into one (1) eye. He said this was regardless of whether it was the same medication, or two (2) different medications. Patient education compiled by the National Institutes of Health (NIH), related to how to instill eye drops, was reviewed on 03/25/14 at 1:00 p.m. The NIH recommended waiting at least five (5) minutes between each drop of the same medication instilled into one (1) eye. According to the Centers for Medicare Services (CMS), Sufficient contact time for eye drops. The eye drop must contact the eye for a sufficient period of time before the next eye drop is instilled. The time for optimal eye drop absorption is approximately 3 to 5 minutes. b) Resident #114 A licensed nurse (Employee #32) was observed on 03/20/14 at 7:50 a.m. as she administered a corticosteroid inhaler ([MEDICATION NAME]) to Resident #114. The nurse did not instruct the resident to rinse her mouth with water, then spit out the water, after the resident inhaled the steroidal medication. As a result, the resident did not rinse and spit after she inhaled the medication. The Federal Drug Administration (FDA) states that failure to rinse the mouth after using an inhaler may place a resident at risk for developing oral yeast overgrowth which is often referred to as thrush. On 03/25/14 at 12:20 p.m., the DON agreed that when [MEDICATION NAME] inhalers were administered, the resident should rinse his/her mouth with water and spit afterward. At 12:30 p.m. on 03/25/14, the pharmacist said that when a [MEDICATION NAME] inhaler was administered, the pharmacy's guideline includes having the patient to rinse the mouth and spit afterward.",2018-05-01
6047,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-03-27,356,B,0,1,R3PM11,The facility failed to ensure the posted nurse staffing data was completed and available for viewing by the residents and/or visitors. The total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift were not posted for day shift in Building 1. This had the potential to affect more than a limited number of residents and/or visitors. Facility census: 135. Findings include: a) The completion of the initial tour of building one (1) of the facility took place on 03/17/14 at 12:15 p.m. Observations at and near the nurses' station revealed the facility had not posted the staffing numbers for day shift on 03/17/14. An interview with Employee #119 (nursing supervisor) and Employee #25 (assistant director of nursing) revealed the facility had not posted the required staff posting for 03/17/14 day shift. They said the employee who normally completed the posting was not working on 03/17/14. The nurses went on to say that no other employee had completed this posting on 03/17/14.,2018-05-01
6048,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-03-27,371,E,0,1,R3PM11,"Based on observation, staff interview, and policy review, the facility failed to store food in a sanitary manner in the clean utility room refrigerator in Building 2. This practice had to potential to affect more than a limited number of residents. Facility census: 135. Findings include: a) A tour was conducted of the facility on 03/17/14 at 1:15 p.m. At 1:30 p.m. the refrigerator was examined in Building 2's clean utility room. There was a piece of cake wrapped in foil with a label on it stating (Resident name) 1-19-14 and a soggy sandwich wrapped in cellophane and in a brown paper bag that was unlabeled. Employee #42 (registered nurse) stated the facility practice was to throw the residents' food away after one (1) week. She discarded both items at 2:00 p.m. She also said the nurse supervisors on the afternoon shift were in charge of monitoring food dates in the resident refrigerators. This matter was discussed with the dietary manager at 10:30 a.m. on 03/19/14. She said nursing was responsible for all resident personal food items in the clean utility refrigerators. During an interview with the director of nursing (DON), at 4:39 p.m. on 03/19/14, she agreed the food needed to be discarded and provided a policy for Storage of Food dated 04/07/06. This policy included, Store potentially hazardous foods under refrigeration . for a maximum of 7 days and discard food when use-by date is unclear. The DON also said the facility practice was for nurses to monitor refrigerators with resident food items in the facility.",2018-05-01
6049,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-03-27,425,E,0,1,R3PM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Centers for Disease Control guidelines, and staff interview, the facility failed to implement procedures for the disposition of expired medications. Observation of the medication storage areas revealed vials of expired tuberculin testing serum, insulin and influenza vaccine. This had the potential to affect more than an isolated number of residents. Resident identifier: #45. Facility census: 135. a) Resident #45 During an observation of the A Wing medication cart, on 03/17/14 at 1:05 p.m., one (1) partially used vial of Humalog insulin was found for Resident #45. The vial contained a date to discard on 01/25/14. It was nearly empty, and had not been discarded. A licensed nurse (Employee #80) acknowledged that all multi-dose vials must be dated when first opened, and discarded according to facility policy. b) Aplisol tuberculin testing serum At 1:22 p.m. on 03/17/14, the medication storage refrigerator for Building 1 was observed with Employee #119, a licensed nurse. An opened and partially used fifty (50) test vial of Aplisol was dated as having been opened on 01/30/14. This tuberculin testing serum is injected beneath the skin of residents and employees, and used as a screening test for the presence of [DIAGNOSES REDACTED]. Employee #119 said she would check to see when this vial should be discarded. The director of nursing (DON) produced storage recommendations for Aplisol on 03/19/14 at 4:30 p.m. According to the facility's policy, vials of Aplisol must be dated when opened, and any unused portion discarded after thirty (30) days. c) Flulaval influenza vaccine On 03/17/14 at 1:22 p.m., the medication storage refrigerator for Building 1 was observed with a nurse, Employee #119. An opened and partially used five (5) milliliter (ml) vial of Flulaval influenza vaccine was dated as having been initially opened on 12/31/13. This vial can provide influenza vaccinations for ten (10) people. Employee #119 said she would check to see when this vial should be discarded. On 03/17/14 at 2:25 p.m., the assistant director of nursing (ADON) Employee #25, said the influenza vaccine was supposed to have been discarded thirty (30) days after having been opened. She said she would dispose of that vial today. The DON produced storage recommendations for influenza vaccine on 03/19/14 at 4:30 p.m. According to the facility's policy vials of Flulaval influenza vaccine must be dated when opened and discarded after twenty-eight (28) days after initially opened. d) Centers for Disease Control (CDC) According to the Centers for Disease Control (CDC), once a multi-dose vial has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within twenty-eight (28) days unless the manufacturer specifies a different (shorter or longer) date for that opened vial",2018-05-01
6050,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-03-27,431,E,0,1,R3PM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of recommendations from the Centers for Disease Control (CDC), policy review, and staff interview, the facility failed to ensure medications were labeled and dated properly. Vials of insulin did not contain expiration dates. Two (2) of eight (8) medication carts contained expired vials of insulin. Resident identifiers: #274 and #45. Facility census: 135. Findings include: a) Resident #274 Observation of the B Wing medication cart, on [DATE] at 1:00 p.m., revealed a partially used vial of Novolog insulin. There was no date on the vial, or on the box it came in, to indicate when the insulin vial had initially been opened. Upon inquiry, registered nurse (Employee #68) said the vial should have been dated when it was first opened for use, and it had not been dated. Employee #68 said the insulin must be discarded after twenty-eight (28) days of opening. Without a date inscribed, it would not be known when this vial should be discarded. The director of nursing (DON) produced insulin storage recommendations on [DATE] at 4:30 p.m. According to the facility's policy, vials of Novolog insulin may only be used for 28 days after having been initially opened. b) Resident #45 During an observation of the A Wing medication cart, on [DATE] at 1:05 p.m., one (1) partially used vials of Humalog insulin was found for Resident #45. A partially used vial of Humalog insulin contained no date to indicate when it had first been opened. A licensed nurse (Employee #80) acknowledged that all multi-dose vials must be dated when first opened, and discarded according to facility policy. Without a date inscribed, it would not be known when this vial should be discarded. The DON produced insulin storage recommendations on [DATE] at 4:30 p.m. According to the facility's policy, vials of Humalog insulin may only be used for twenty-eight (28) days after having been initially opened.",2018-05-01
6051,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-03-27,441,E,0,1,R3PM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain an effective infection control program designed to provide a sanitary environment. Nursing staff did not demonstrate safe infection control techniques when using a glucometer. Nursing staff also did not properly use personal protective equipment when caring for a resident who had an infection with multi-drug resistant organism. These practices had the potential to transmit microorganisms and infection, and could potentially affect more than a limited number of residents. Resident identifiers: #11 and #96. Facility census: 135. Findings include: a) Resident #11 On 03/17/14 at 4:07 p.m., licensed nurse (Employee #2) cleaned the hand-held, blood sugar testing machine after completing a blood sugar test on Resident #69. She cleaned the machine with a disinfectant wipe, then placed the machine directly onto the resident's bed. It laid on the bed for several minutes. The nurse picked the machine up from the resident's bed and placed it back onto the medication cart with no further cleaning. The nurse then entered the room of Resident #11. At 4:14 p.m. on 03/17/14, Employee #2 completed a blood sugar test on Resident #11 without first disinfecting the testing machine that had lain on the bed of Resident #69. This practice had the potential to transmit microorganisms from one resident to another. On 03/27/14 at 11:00 a.m., during an interview with the administrator (Employee #185) and DON, they were informed of the inadequate cleaning of a glucometer between each resident used. The DON was in agreement the nurse did not follow infection control facility practice to prevent cross contamination between each use of the glucometer. b) Resident #96 On 3/17/14 at 4:35 p.m., a nurse (Employee #176) was observed in the room of Resident #96. A sign on the resident's door alerted those who entered this resident was on contact precautions. The directions on the sign instructed those who entered to wear a gown and gloves. Employee #176 was in the resident's room at that time without gloves or a gown. She moved his over-bed table, which had been in contact with the resident's bed, and television stand to where the resident could more easily view his television while lying on his right side. Upon inquiry, Employee #176 said she did not have to gown or glove unless she had direct contact with the person. She did not wash her hands. She performed a quick hand sanitation at the door by using disinfectant from a dispenser inside the room. Employee #176 then removed a large, yellow, plastic wet floor sign from inside the room and carried it to another hall. A brief review of the medical record on 03/17/14 at 4:40 p.m. found this resident has had two (2) types of multi-drug resistant organisms - methicillin resistant staphylococcus aureus and Carbapenem-resistant [DIAGNOSES REDACTED] Pneumoniae. The physician ordered contact precautions to try to prevent the spread of microorganisms and infection. An interview was conducted with the director of nursing (DON) on 03/17/14 at 4:45 p.m. The DON said staff were supposed to put on gloves and a gown when they were in this room touching the resident or any of the inanimate objects in the room. She said the nurse should have worn gloves and gowns in this instance. The DON said she would track down the sign and make sure it was disinfected.",2018-05-01
6052,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-03-27,469,D,0,1,R3PM11,"Based on observation and staff interview, the facility failed to maintain an effective pest control program. During an observation, there was evidence of pest infestation in room C-9. This had the potential to affect more than a limited number of rooms. Facility census: 135. Findings include: a) Room C-9 On 03/27/14 at 2:15 p.m., the director of maintenance and the nursing home administrator verified the presence of ants in room C-9 near the heating/air unit located under the window. The director of maintenance also provided the most recent pest control log, which indicated a building perimeter spray had been completed on 02/24/14.",2018-05-01
6053,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-03-27,520,E,0,1,R3PM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and medical record review, it was determined the facility's quality assessment and assurance (QA&A) committee failed to identify and/or develop an effective plan of action to correct quality deficiencies in the facility's daily operations in which it did have or should have had knowledge. During the survey, from 03/17/14 through 03/27/14, it was identified the facility had an issue with infection control practices. The facility had already identified infection control issues in their QA&A committee, prior to the issues discovered during the survey. In addition, after the facility became aware critical laboratory work was not obtained for a resident. The QA&A committee failed to implement corrective actions to ensure this situation did not reoccur. Residents #96 and #31 were affected; however, the practices had the potential to affect more than an isolated number of residents. Facility census: 135. Findings include: a) Infection Control On 3/17/14 at 4:07 p.m., a licensed practical nurse (LPN - Employee #2) was observed cleaning a glucometer after completing a blood sugar test. Employee #2 laid the glucometer on a resident's bed, then picked up the glucometer and placed on the medication cart with no further cleaning. The employee then used the glucometer with another resident without cleaning the glucometer. This practice had a potential for cross contamination of the glucometer. At 11:00 a.m. on 03/27/14, during an interview with the administrator and director of nursing (DON), the DON was informed of the failure to adequately clean a glucometer between each resident. The DON was in agreement the nurse did not follow infection control practices to prevent cross contamination between each use of the glucometer. In addition, the DON stated infection control issues and monitoring of staff infection control practices was presented during the QA&A meetings. b) Resident #96 On 3/17/14 at 4:35 p.m. a nurse (Employee #176) was observed in the room of Resident #96. A sign on the resident's door alerted those who entered this resident was on contact precautions. The directions on the sign instructed those who entered to wear a gown and gloves. Employee #176 was in the resident's room at this time without gloves or a gown. She moved the resident's over-bed table, that had been next to the resident's bed, and television stand to where the resident could more easily view it while lying on his right side. Upon inquiry, Employee #176 said she did not have to gown up or glove up unless she had direct contact with the person. She did not wash her hands, but instead performed a quick hand sanitation at the door by using disinfectant from a dispenser inside the room. Employee #176 then removed a large, yellow, plastic wet floor sign from inside the resident's the room and carried it to another hall. A review of the medical record, on 03/17/14 at 4:40 p.m., found the resident had two (2) types of multi-drug resistant organisms. The physician ordered contact precautions to try to prevent the spread of microorganisms and infection. An interview was conducted with the DON on 03/17/14 at 4:45 p.m. The DON said staff were supposed to put on gloves and a gown when they were in Resident #96's room touching the resident or any of the inanimate objects in the room. She said the nurse should have worn gloves and a gowns at the time of the observation. c) Resident #31 A review of the medical record, on 03/24/14 at 4:00 p.m., revealed the resident was admitted to the facility on [DATE] from an acute care hospital. The hospital's admission history and physical (H&P), dated 12/06/13, revealed Resident #31 had slight weakness on the left side, and a possible [MEDICAL CONDITION]. The resident also had chronic venous stasis and [MEDICAL CONDITION] of her left lower extremity. The H&P also noted the resident was on [MEDICATION NAME] with a therapeutic INR. The INR result was 2.89 on 12/06/14. (PT/INR ([MEDICATION NAME] time and international normalized ratio) is a laboratory (lab) test used to monitor bleeding and clotting time for those who are on anticoagulation therapy, such as with [MEDICATION NAME]. The therapeutic range of the INR is between 2.0 and 3.0.) The hospital's discharge summary, dated 12/10/14, indicated the primary [DIAGNOSES REDACTED]. Another discharge [DIAGNOSES REDACTED]. A PT/INR at the hospital on [DATE] showed an INR value of 1.69. Initial physician's orders [REDACTED]. A registered nurse completed a situation background assessment recommendation (SBAR) on 12/29/14 at 1:45 p.m. The nurse stated (typed as written) Resident d/t (due to) have PT/INR on 12/17/13. Lab slip not filled out and lab was not drawn. Resident on ATB (antibiotic) therapy. The nurse notified the physician, who then gave orders for an immediate PT/INR. The INR was 1.08. The physician increased the daily dose of [MEDICATION NAME] to 5 mg daily, and ordered a repeat PT/INR on 01/01/14. On 01/01/14 the INR was only 1.19. The physician increased the daily dose of [MEDICATION NAME] to 6 mg daily, and ordered a repeat PT/INR on 01/03/14. The INR was 1.32 on 01/03/14. The physician increased the daily dose of [MEDICATION NAME] to 6.5 mg. daily, and ordered a repeat PT/INR on 01/06/14. Review of nursing notes, dated 01/04/14 at 10:25 p.m., found a change in the resident's condition. Registered nurse Employee #69 assessed a discoloration to the resident's left lower extremity (LLE). The LLE was (typed as written) blue in color from ankle to just below knee, foot was of normal color, pedal pulse was faint, pt (patient) did have +3 [MEDICAL CONDITION] present. (The doctor) was notified of findings. The resident was transported to the local hospital by emergency medical services. The resident was admitted to the hospital for a [MEDICAL CONDITION] of the LLE. She returned to the facility on [DATE]. The INR on the day of discharge from the acute care facility was 2.34. An interview was conducted with the director of nursing (DON) on 03/25/14 at 9:00 a.m. Upon inquiry, she said there have been no changes or corrective measures put into place following the missed lab work for this resident, to ensure no PT/INRs were inadvertently omitted for any other residents in the future. She said there had been no re-education of facility staff related to monitoring lab results for residents who were on anticoagulation therapy. The DON said the facility used a quality improvement tool whenever a resident was admitted to the hospital with [REDACTED]. The purpose of this tool was to see if there was anything they could have done differently, or that they may have missed. She provided copies of this tool related to the 01/04/14 hospitalization of Resident #31. Registered nurse (Employee #119) and Employee #165 (registered nurse) completed this tool on 01/06/14. The DON said both of these quality improvement tool reports had similar findings, neither of which addressed any blood tests. She speculated that was the reason it did not trigger to the ADON or the DON that a missed lab may have potentially contributed to a hospitalization . The resident was on antibiotics, and that also was not on the quality improvement tool report. The DON produced the 12/29/13 incident report sheet for the missed PT/INR that was due on 12/17/13. She said she did not know if a full investigation was done to see why the error occurred. An interview was conducted with the Building 1 nursing supervisor, Employee #119, on 03/25/14 at 9:20 a.m. She also said she did not recall if an investigation was done related to the missed PT/INR on 12/17/13. She stated she did not recall if there was any staff education related to ensuring PT/INR's were monitored and not missed.",2018-05-01
6054,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-05-22,441,F,1,0,N62L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, facility policy review, resident interview, family interview, and staff interviews, the facility failed to maintain an Infection Control Program to prevent, to the extent possible, the onset and spread of infections. Transmission based precautions were not consistently ordered based on the Centers for Disease Control and Prevention (CDC) recommendations and according to the facility's Infection Control Policy. Staff were also unaware of what type of isolation precautions were required according to CDC recommendations. In addition, there was a failure to maintain effective communication for staff and visitors regarding specific isolation requirements for residents who were in isolation. These practices had the potential to affect all residents residing in the facility. Resident identifiers: #20, #127, and #89. Facility Census: 160. Findings include: a) Building 1 During the initial tour on 05/18/15 at 11:15 a.m., observation revealed Contact Precaution and/or Special Contact Precaution signs posted on the doors of Rooms F2, F5, F6, F9, F15, G-Hall Special Care (GSC), and G13. For each room, there was Personal Protective Equipment (PPE) available on the door or in a cart in the hallway next to the door. The doors to Rooms F5 and F9 had both Contact Precaution and Special Contact Precaution signs posted. 1. Resident #20 On 05/18/15 at 11:15 a.m., a sign for contact isolation was observed posted on the door of Resident #20's room. A cart containing PPE was observed in the hallway, next to the door to the room. The resident was observed standing in the doorway. Nurse Aide (NA) #192 was observed asking Resident #20 to please remember to put a mask on if he planned on leaving his room. At that time, NA #192 was asked why the mask was necessary. She said the resident had MRSA (methicillin resistant Staphylococcus aureus) in his sputum. She stated when leaving his room, he needed to wear a mask, and anyone entering the room, also needed to wear a mask. A review of the medical records for Resident #20, on 05/18/15 at 2:00 p.m., identified the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the progress notes identified a general progress note entered on 04/26/15. It indicated the resident had a productive cough with white sputum observed. The note also indicated staff maintained contact precautions and the resident was compliant with wearing a mask. A nurse's note, entered on 05/15/15, indicated the sputum culture and sensitivity results were received. A new order was written for the antibiotic [MEDICATION NAME] to be administered intravenously for fourteen (14) days. There was also an order [REDACTED]. 2. Resident #127 At 11:20 a.m. on 05/18/15, Resident #127's room had a contact isolation sign posted on the door, as well as PPE hanging from the door. Resident #127 was observed lying in his bed. On 05/19/15 at 8:40 a.m., a review the medical records for Resident #127 revealed the resident was admitted to the facility in February 2015, due to diabetic ulcers on both feet. The resident's capacity to make medical decisions form indicated he demonstrated capacity to make medical decisions. It was signed and dated by the physician on 02/21/15. The resident's admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 02/27/15, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15. This is the highest possible score and indicated an intact cognitive status. A wound culture of Resident #127's left foot, dated 02/12/15, indicated heavy growth of [MEDICATION NAME] Faecium, susceptible to [MEDICATION NAME] and [MEDICATION NAME]. The medical record also contained a physician's orders [REDACTED]. Further review identified an additional order dated 05/02/15, to initiate contact precautions due to heavy growth of MRSA in the wound. On 05/19/15 at 11:00 a.m., Resident # 127 was observed propelling himself in his wheelchair through the halls of Building 1. Upon inquiry as to the isolation sign on his door and the isolation equipment outside the room, the resident said he used to have an infection of MRSA in a wound on his foot. He said he had completed the antibiotics, but staff kept the sign and equipment there just as added protection. When asked if all staff members entering his room were consistent with the wearing the PPE, he said, Yes. He said they all wore gloves when entering his room. When asked about the use of the gowns, he said the gowns were only worn sometimes. 3. Resident #89 On 05/18/15 at 11:25 a.m., Resident #89's room was observed with a sign posted for contact isolation precautions. There was also a cart containing PPE located outside the room. No one was in the room. At that time, observation revealed Resident #89 being pushed down the hall in a wheelchair. The person pushing the resident was not wearing gloves. She said, If you are looking for him, he is right here. The person, a family member, said she was taking the resident for a walk in the halls. Upon inquiry as to why the resident was under isolation precautions, she said he previously had MRSA in his nasal cavity, as well as his urine. She said it progressed to [MEDICATION NAME]-Resistant [MEDICATION NAME] (VRE) of the urine and stool, and from there it further progressed into Carbapenem-Resistant [MEDICATION NAME] (CRE) of the urine and stool. The family member said Resident #89 did not currently have a roommate. During this conversation, the resident propelled himself down the hall in the wheelchair, and ran his left hand along the handrail in the hallway. Upon inquiry, the family member said the resident was incontinent of bowel and bladder due to a past stroke. The family member indicated she and/or another family member were in the facility daily. When asked if she wore gloves and a gown when visiting with the resident, she said, No. At 10:10 a.m. on 05/19/15, another visitor was observed in Resident #89's room. The contact isolation sign was posted on the resident's door, as well as the PPE located in the cart outside of the resident's room. The visitor was not wearing gloves or a gown. On 05/18/15 at 3:30 p.m., a review of the clinical records for Resident #89 revealed contact isolation precautions were ordered upon admission on 04/21/15 for MRSA and VRE in the urine, as well as MRSA in the nasal cavity. The nurse's admission note, dated 04/21/15, also indicated a moist productive cough. Further review of the medical record identified a urinalysis with a culture and sensitivity dated 05/08/15. It indicated CRE at a count greater than 100,000, colony-forming unit per milliliter (CFU/ML). b) Building 2 The initial tour of Building 2, on 05/18/15 at 12:00 p.m., revealed Rooms ASC, A3, A5, D6, and D11 had Contact Precaution signs posted on the doors and PPE hanging on the doors. Rooms A4, A11, and C1 had PPE hanging on the doors, but no signs regarding contact precautions were posted. c) The signs for Contact Precautions instructed families and visitors to stop, and follow the instructions on the information sheet. The instructions indicated, everyone must wash their hands when entering and leaving the room. It further instructed doctors and staff to gown and glove at the door. It also instructed doctors and staff to use patient dedicated or disposable equipment, and to clean and disinfect the equipment. The signs for Special Contact Precautions instructed visitors to see the nurse prior to entering the room. Further instructions on the signs indicated to wear gloves when entering the room, and to remove the gloves before leaving the room. The signs also instructed everyone to wash hands with soap and water before and after patient care and when leaving the room, to wear a gown when entering the room, and to remove the gown prior to leaving the room. It also instructed everyone to use disposable or single use patient care equipment, bleach wipes on common-use equipment, limit patient transport, and to use appropriate barrier protection when necessary. d) On 05/18/15 at 1:30 p.m., a review of the facility's Infection Control policy, with a revised date of January 2014, revealed the following: -- Heading - Isolation - Categories of Transmission-Based Precautions -- Policy Statement - . Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. -- The policy interpretation and implementation section indicated: Based on CDC definitions, three types of Transmission-Based Precautions (airborne, droplet and contact) have been established. The remainder of the policy outlined the three (3) types of Transmission-Based Precautions, and how to implement each of the three (3). -- Contact Precautions indicated, in addition to the Standard Precaution of hand washing and the use of gloves, a gown should be worn when having contact with the resident, or items in the resident's room, which may be potentially contaminated. -- Droplet precautions were to be implemented in addition to Standard Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large particle droplets (larger than five (5) microns in size) that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). PPE needed for droplet precautions included the addition of masks, in addition to Standard Precautions. e) During the survey, nursing staff interviews revealed differing understandings regarding how infection control practices were implemented, should be implemented, and/or were communicated as necessary. 1. At 4:55 p.m. on 05/18/15, Nurse Aide (NA) #25, when asked what the difference was between Contact Precautions and Special Contact Precautions, replied, I have no idea. When asked how she was to know what PPE to use prior to entering a room that indicated the need for PPE, she said she always wore gloves, a gown, and a mask. She said she did this because the NAs were not always made aware of what the infection was or where it was located, such as in the urine, or sputum, etc. 2. On 05/18/15 at 5:00 p.m., NA #192 was asked about the difference between Contact Precautions and Special Contact Precautions. NA #192 did not know the difference between the two (2) precautions. When asked if the presence of both signs posted on a resident's door required precautions different from the presence of only one (1) sign posted on a resident's door, NA #192 again said she did not know. When asked how she was to know when to wear a mask, when neither of the signs posted indicated the need to wear a mask, she said, Sometimes the nurses tell you what to do. 3. At 10:00 a.m. on 05/19/15, upon inquiry, Registered Nurse (RN) #210 said the Contact Precautions and Special Contact Precautions signs meant the same thing, but were just worded different. When asked about the protocol for entering residents' rooms where contact isolation was ordered, RN #210 said staff had to glove and gown. RN #210 said when there were residents with infections in their sputum, staff needed to wear masks. 4. On 05/19/15 at 10:05 a.m., NA #132 was asked which PPE was necessary prior to entering a room where a contact precaution sign was posted. NA #132 said, It depends on the resident. She said if a resident had Methicillin Resistant Staphylococcus aureus (MRSA) in the sputum, she would wear gloves, a gown and a mask. Upon inquiry as to how she would know where the infection was located, and if there was a need to wear a mask, she said the Nurse Aides were not always informed. NA #132 said the nurses were the only ones who specifically needed to know the type of infection and where it was located. 5. At 10:15 a.m. on 05/19/15, NA #109, upon inquiry as to what was the required PPE used with contact precautions, said staff needed to wear gloves, a gown, and sometimes a mask and booties. When asked how she was made aware of the required PPE, she said she did not always know because the information was not always passed on. f) On 05/18/15 at 1:45 p.m., upon inquiry, the Administrator said the facility had two (2) Assistant Directors of Nursing (ADONs), one for each of the two (2) buildings. She said they were responsible for the tracking and trending of the infections located in their assigned buildings. The Administrator was asked to provide a line listing or report regarding the infections currently in the facility. She said the facility utilized a form identified as a bed board, which indicated what infections were currently being treated or under Transmission Based Precautions, and the room numbers. g) On 05/19/15 at 3:45 p.m., interviews were conducted ADON-RN #193 and ADON-RN #38 in separate locations, asking the same questions. 1. The interview with ADON-RN #193, at 3:45 p.m. on 05/19/15, revealed she was in charge of the infections in Building 2 of the facility. When asked what types of isolation precautions were used by the facility she stated, We use contact precautions unless it is Flu season, then we will use droplet precautions and will wear masks and put signs at the entrances, ADON-RN #193 was asked what type of PPE was used for standard, contact, and droplet precautions. She indicated for standard precautions gloves were worn, for contact precautions gloves and a gown were worn, and for droplet precautions gloves, a gown, and a mask were worn. ADON- RN #193 was asked how she tracked the infections Building 2. She said she maintained a log of infections. She stated every morning she looked through the physician orders [REDACTED]. RN #193 stated once she had the orders, she reviewed the laboratory (lab) test results of cultures to determine the organism. She stated she updated her log at least once a week or more often if possible. RN #193 was asked for how long after isolation precautions were discontinued, the PPE remained by/or on the resident's door. She indicated as soon as the order was obtained from the physician to discontinue the isolation precautions, the PPE should be removed as soon as possible. When asked how residents were cohorted, ADON-RN #193 stated they tried to cohort similar infections together in the same room. She stated, at times it was not always possible to cohort residents with the same organisms together. RN #193 said in that case, residents with an infection could be cohorted with residents who are not immunosuppressed and had no open portals such as a feeding tube, a catheter, or a pressure ulcer. She stated this could only be done if the resident was on contact precautions and the infection was contained. ADON-RN #193 was then asked how the different types of precautions used were communicated to staff. She stated, We use the signs posted on the door which tells you what type precautions should be used with the resident and also tells the staff what personal protective equipment should be used. When asked if she was familiar with the facility's isolation policy, ADON-RN #193 stated she was familiar with it, and it was located at the nurses' station for reference should she have doubts. 2. The interview with ADON-RN #38, at 3:45 p.m. on 05/19/15, revealed she was in charge of the infections in Building 1. When asked what types of isolation precautions were used by the facility she stated, Standard and contact precautions are the only types we use, other than Flu season. During Flu season we use droplet precautions and post signs at the entrance of the facility, and provide masks at the entrance. ADON-RN #38 was asked what type of PPE was used for standard, contact, and droplet precautions. She said gloves were worn for standard precautions, as well as eye guards if there was a potential for splashing. For contact precautions, she said gloves, a gown, a mask if needed, and eye protection were worn. ADON-RN #38 was asked how she tracked the infections in her building. She indicated she maintained a log of infections. She said she tracked the infections on the log, and updated the log when antibiotics were ordered or specimens were sent to the laboratory. When asked how she identified trends of infections, ADON-RN #38 indicated she monitored her infection log to see if there were any acute outbreaks. ADON-RN #38 was asked how long after isolation precautions were discontinued the PPE remained by/or on the resident's door. She indicated as soon as the order was obtained from the physician to discontinue the isolation precautions, the PPE should be removed as soon as possible. When asked how residents were cohorted, ADON-RN #38 stated the residents were cohorted according to their past medical history. She said if they had an active infection, they were cohorted with someone who had the same active infection, or someone who was not immunocompromised. ADON-RN #38 was asked how staff members other than nurses knew what PPE was required prior to entering a room. She said they should know what to use by reading the signs posted on the door, and the nurses told them as well. When asked if she was familiar with the facility's isolation policy regarding Airborne and Droplet Precautions, ADON-RN #38 said, Yes, and we are to follow it. At that time, the facility's policy regarding Droplet Precautions was reviewed. She agreed Resident #20, who resided in Building 1, had a final sputum culture, dated 05/15/15, which indicated MRSA in the sputum, and also had a history of [REDACTED]. ADON-RN #83 verified even though staff and the resident had been wearing masks, the sign posted on the resident's door did not instruct individuals to wear a mask. She further verified an individual without the proper instructions, or knowledge of the infection, could potentially place themselves as well as others at risk of contamination. h) On 05/20/15 at 11:20 a.m., Physical Therapist #233 was asked how she knew which PPE to wear when entering a resident's room to either transport a resident to therapy, or to provide therapy services. She replied, I go by what the sign says to do. I do not make judgement calls on my own. i) At 11:40 a.m. on 05/20/15, the Medical Director was asked how he determined the types of isolation precautions to be ordered. He said when ordering and discontinuing isolation precautions, he tells the nurses to write the orders according to the facility's policy. He further indicated the isolation precautions should be based on the CDC (Centers for Disease Control and Prevention) recommendations. The medical director was made aware the nurses only wrote orders for contact precautions, and that only contact precautions were ordered for Resident #20, whose medical record indicated the resident had a productive cough with white sputum and recurrent MRSA Pneumonia. He was also made aware the facility's policy was based on the CDC recommendations, which indicated the use of Airborne and Droplet precautions as well as Contact precautions. The medical director said if the policy indicated droplet precautions, that was what should have been ordered. He said this matter would be brought to the Quality Assurance and Assessment committee's attention today (05/20/15), as the facility had not been following their Infection Control policy based on CDC (Centers for Disease Control) recommendations. j) At 12:00 p.m. on 05/18/15, the administrator was made aware of the three (3) rooms where isolation precaution equipment was hanging with no signs posted on the doors (Rooms A4, A11, and C1). All three (3) of the rooms had residents currently under contact precautions. On 05/20/15 at 1:30 p.m., the Administrator was made aware of the concerns regarding the posted signs and communication regarding infection control, as well as the appropriate classification of isolation orders per facility policy and CDC recommendations. She voiced there was a need to review the facility's policy and provide further education regarding isolation procedures. Also discussed at this time were the two (2) types of contact isolation signs observed posted in the facility. At 1:45 p.m. on 05/20/15, the administrator was made aware of the observations made during the initial tour on 05/18/15, and that when the rooms were observed on 05/19/15, contact precaution signs were posted. The administrator agreed someone had most likely put the signs up between the 12:00 p.m. observation on 05/18/15 and the observation made on 05/19/15 at 4:00 p.m. The rooms observed during the initial tour and again on 05/20/15 at 8:30 a.m., with two (2) types of contact precaution signs posted were A3, A5, F5, F9, and G13. The administrator was informed nursing staff stated there was no difference in the intent or instructions of the signs, only a different look and some different wording. She agreed this practice had the potential to be confusing to staff and visitors, as to the necessary PPE. The administrator said she was checking to see if there were standardized isolation precaution signs available for the Droplet and Airborne situations, similar to the contact precaution signs the facility currently used. She indicated she was going to communicate with the staff that only one (1) of the signs was to be posted on the doors.",2018-05-01
6778,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-11-06,224,D,1,0,1Q9011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of the facility's abuse policy, the facility failed to ensure two (2) of five (5)residents reviewed were free from neglect. Resident #146 was not provided services related to a wound on the scalp. Resident #13 was not provide prompt services for skin breakdown around her gastrostomy tube. Resident identifiers: #146 and #13. Facility census: 145. Findings include: a) Resident #146 Review of a nurse's progress note dated 08/11/14 at 8:50 a.m., on 11/05/14, revealed Appt (appointment) with Dr. (name) on 8-27-14 @ (at) 10:00 A.M. POA (power of attorney) (POA's name) aware. Interview with the director of nursing (DON) revealed Resident #146 was referred to the physician, a dermatologist, for issues related to her scalp. Results of the consultation were requested at that time. On 11/05/14 at 12:20 p.m., the resident's records from the hospital were obtained. Review of the hospital admission information, dated 10/24/14, found the documentation indicated a wound was located on top of the resident's head with moderate thick purulent drainage. No measurements were recorded. Several photos, taken upon admission were included in the documentation. They showed the wound covered almost the entire top portion of the resident's head. Observation of the photos of the scalp revealed crusted, thickened scab layers covering the top of the resident's head, with matted knotted hair growing through it. Hospital wound care documentation, dated 10/25/14, the day after admission, revealed the wound on top of resident's head had a large amount of thick purulent drainage with noted improvement. The photo revealed many of the previous crusted scab layers were no longer present. On 11/06/14 at 10:25 a.m., an interview was conducted with Employee #117, registered nurse (RN) treatment nurse, concerning Resident #146's scalp and the missed dermatologist appointments. The treatment nurse stated the first time Resident #146's dermatologist appointment was missed was because the resident was admitted to the hospital. The treatment nurse stated, The second appointment was missed because I failed to write the order when I rescheduled it, and I forgot to enter it in the appointment log book, so it was missed. The treatment nurse confirmed it was her error that Resident #146 was not seen by the specialist for the condition of her scalp. At 10:45 a.m. on 11/06/14, an interview was conducted with the director of nursing (DON). The DON said, At one point we were treating her (Resident #146) for psoriasis. In August, when the new company took over, I did the body audit and saw it was a dry area that appeared to be attached. I did not know if it was a tumor or mass and instructed my staff not to scrape at it. I discussed it with the facility physician here and the resident was referred to a dermatologist. Our physician here does not usually refer them, so there was a concern. The first appointment was 08/27/14, but the resident ended up in the hospital. The second appointment was 09/24/14 and the order was not written, so it was missed. When asked if the DON thought there had been a delay in care, the DON replied, I agree there was a delay in care, partly because she was in and out of the hospital due to dysfunctional G tube (gastrostomy tube) issues. b) Resident #13 On 11/04/14 at 2:15 p.m., accompanied by the DON, an observation was made of Resident #13's feeding tube insertion site. The DON removed the split gauze dressing used to cover the site. The site was excoriated and had two (2) small open areas, one (1) at 7:00 o'clock and one (1) at 1:00 o'clock. There was wet bloody drainage noted on the gauze dressing. The DON disposed of the soiled dressing and stated she would get the resident's nurse to apply a clean dressing. When asked about the excoriation and open areas, the DON said she would have to check on the treatment for [REDACTED]. Review of the resident's medical records, on 11/05/14 at 5:10 p.m., revealed no entry about replacing the split gauge dressing around the G tube on 11/04/14. There was also no documentation regarding the excoriation and small open areas around the feeding tube insertion site. No evidence was found that the physician was notified of these areas. The record contained only a late entry referencing the initial dressing change the nurse did at 9:00 a.m. on 11/04/14. On 11/05/14 at 5:33 p.m., the DON was asked what had been done about the resident's excoriation and open areas. The DON said she thought the floor nurse had taken care of it. The DON was informed that the medical record contained only a late entry about the initial dressing which was applied at 9:00 a.m. on 11/04/14. The DON said she would get the treatment nurse to get an order to address it. Review of the medical record, on 11/06/14 at 2:12 p.m. revealed a nursing progress note, dated 11/05/14 at 19:07 p.m. (7:07 p.m.), by the treatment nurse. It said, On assessment noted G site very red with some pinpoint excoriation surrounding entire G site extending outward 2 cm. Old dark green drainage noted on old split sponge. No blood noted. No foul odor detected Phone Dr. (name) and received new orders for G-site treatment .Order faxed to pharmacy. Staff aware of new orders. The resident's excoriation and open areas were observed by the DON at 11/04/14 at 2:15 p.m. The facility neglected to notify the physician regarding the resident's skin condition until 11/05/14 at 7:07 p.m. This was more than 24 hours after the areas were observed by the DON. c) Review of facility's abuse policy, the section entitled Policy Interpretation and Implementation number 4.f. indicated Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.",2017-11-01
6779,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-11-06,246,D,1,0,1Q9011,"Based on observation and staff interview, the facility failed to ensure three (3) of forty (40) residents observed during the morning meal on 11/04/14 received services in the facility with reasonable accommodations of their individual needs. The table at which Resident #24 was seated was too high. Residents #15 and #79 were left in a reclined position after receiving their meal and both residents were not positioned at a distance from the table to allow them easy access to their meal. Resident identifiers: #24, #15, and #79. Facility census: 145. Findings include: a) Observation of the morning meal on 11/04/14 Observation of the morning meal at 8:15 a.m. on 11/04/14 found three (3) residents, #131, #15 and #79, seated together at a table just inside the entrance to the dining room. The three (3) residents received their meals simultaneously. Residents #15 and #79 were seated in a reclined position in scoop chairs, which were positioned more than a foot away from the table. Resident #131 began feeding herself. Residents #15 and #79 were sleeping and did not attempt to feed themselves. At 8:37 a.m. on 11/04/14, Resident #131 had finished with her meal and she left the dining room. A nursing assistant (NA), Employee #139, arrived at the table to assist Residents #15 and #79. The NA immediately sat both residents upright and scooted their scoop chairs up to the table. NA #139 asked Resident #15 if she was going to wake up and eat. The resident began feeding herself. NA #139 attempted to get Resident #79 to feed herself and when the resident did not respond, the NA sat down to feed her. NA #139 stated Resident #15 usually feeds herself. Further observation of Resident #24 found she was also seated in a, scoop chair, at a second table. The resident's nose was level with the table at which she was seated. The resident was observed feeding herself from a bowl resting on her lap. Employee #175, a registered nurse (RN), was sitting at the table with Resident #24. At 8:45 p.m. on 11/04/14, RN #175 confirmed the table was, too low, for the resident. She said the resident's seating arrangement should have been changed because Resident #24 had just recently been placed in the scoop chair. She needs a lower table, she was in another chair and we just put her in this chair.",2017-11-01
6780,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-11-06,279,D,1,0,1Q9011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to develop comprehensive care plans to address the application and removal of assistive devices and treatments for prevention of contractures for three (3) of five (5) residents identified with a limited range of motion and contractures. Resident identifiers: #8, #25 and #146. Facility census: 145. Findings include: a) Resident #8 Review of the resident's medical record on the morning of 11/04/14 found the resident's [DIAGNOSES REDACTED]. Further review of the resident's most recent full minimum data set (MDS), an annual, with an assessment reference date (ARD) of 02/14/14, Section (S) found the resident had bilateral contractures of the elbows, ankles, knees and hips. Contractures were also present in the left hand and wrist. Section (G) entitled Functional Status, indicated the resident was total care with all ADLs. On 10/28/14 an order was written for a palm guard to be worn at all times, except during bathing, to the left hand. Observation of the resident at 9:30 a.m. and 10:22 a.m. on 11/04/14 found the palm guard was not present on the left hand. The resident was in bed and in her room. At 10:27 a.m. on 11/04/14, the resident's Nurse Aide (NA) #67, was asked where she would find communication / direction regarding the application of the palm guard. NA #67 stated she could look at the resident's care orders located in the Kiosk for the NAs. She demonstrated how to use the Kiosk and stated the Kiosk directed the resident to wear the guard for 8 hours a day. When asked how she would know when the eight hours started and ended, she said, I wouldn't, therapy puts the splint on her. She verified the current information in the Kiosk regarding the use of a palm guard did not say to wear it at all times. At 10:45 on 11/04/14, Employee #110, a registered nurse (RN), observed the resident without the palm guard. At that time, RN #110 said the current order for the palm guard said to wear it for eight (8) hours a day. She also said therapy applied the palm guard, not the nursing staff. At 11:03 a.m. RN #110 said she was mistaken and the order did say to wear the palm guard at all times. Further review of the current care plan at 1:00 p.m. on 11/04/14, found a problem addressing contractures, initiated on 03/09/07. The goal associated with this problem was, Skin will remain intact, free from [DIAGNOSES REDACTED], breakdown, excoriation until next review. The interventions related to accomplishment of the goal did not include the use of a palm guard. The occupational therapist (OT), Employee #204, was interviewed at 1:50 p.m. on 11/04/14. She stated she had been putting the palm guard on the resident. She stated she had been working with the resident since 03/19/14 and had tried various devices to address the resident's contractures. When asked if she worked 7 days a week she stated, No. When asked if she was aware an order was written on 10/28/14 for the resident to wear the palm protector at all times, she said she was aware of the order, but she should have discontinued this order. She said she had applied the palm protector herself earlier this morning after finding it in the resident's drawer and she did not know why the resident was not wearing the palm guard. She also confirmed the guard would need to be removed periodically to check the condition of the resident's skin. Employee #175, the MDS coordinator, was interviewed at 3:19 a.m. on 11/04/14. She verified the current care plan did not address the use of the palm guard. b) Resident #25 Review of the resident's medical record found an [AGE] year old female whose [DIAGNOSES REDACTED]. The current MDS, a quarterly, with an ARD of 08/17/14 found the resident had contractures of the right elbow and the right shoulder. At 5:05 p.m. on 11/04/14, observation of the resident with Employee #181 a registered nurse (RN), found the resident in bed wearing a splint to her right hand. RN #181 stated therapy applied the splint and took it off when they left for the day. RN #181 was asked if therapy staff were still in the building. She then confirmed the therapy department had already left the building for the day. When asked who was going to remove the splint, she stated she would remove the splint. Further review of the medical record found no physician orders for the splint and no mention of the splint in the resident's current care plan. The current care plan, revised on 01/17/14, addressed the resident's limited range of motion and the goal associated with the focus problem was, Will receive assistance necessary to meet ADL (activities of daily living) needs. Approaches included, Refer to the therapy Plan of Treatment in the medical record for more detail. Uses assistive/adaptive equipment w/c (wheel chair), and PT/OT (physical therapy and occupational therapy) / speech evaluation and treatment per physician orders. At 5:05 p.m. on 11/04/14, the director of nursing (DON) stated the therapy manager, Employee #197 was still in the building. Employee #197 was interviewed with the DON. Employee #197 confirmed she was the only therapist remaining in the facility and she was unaware the resident was still wearing the hand splint; therefore, she had no plans to remove the splint before she left the building. c) Resident #146 (closed record) Review of the discharge MDS with an ARD of 09/02/14, Section (S) found the resident had contractures of both hands, wrists, ankle, knees and hips. Review of the current care plan, updated on 10/24/14 found a focus problem addressing contractures. The goal associated with this problem was the resident will have no skin breakdown noted daily through the next review. Approaches included: Administer medications as prescribed by MD (doctor), apply lotion as needed, body audit weekly, monitor for incontinence, pressure relieving mattress. At 9:36 a.m. on 11/05/14, the DON was asked what the facility was doing to prevent further decline in range of motion and how the facility addressed the resident's contractures. The DON provided copies of therapy notes indicating the resident received OT from 05/16/14 through 06/13/14. A note written by the occupational therapist on 04/30/14 included, .Staff educated provided to perform PROM, (passive range of motion), gentle stretch (illegible), B UE ( bilateral upper extremities) as pt. tolerates during ADL, CNA's (certified nursing assistants) verbalized understanding The DON was unable to provide any documentation of who attended the education, how the education material would be communicated to new staff and no evidence the care plan referenced how staff would provide passive range of motion and gentle stretching of the bilateral upper extremities and how long staff were to continue providing the treatment. The DON then said the resident was discharged from the facility on 10/28/14 and the current care plan may not have been updated before the resident left the facility. The care plan in effect at the time of the staff education on 04/30/14 was reviewed with the DON. The care plan in effect at that time was the same care plan that was updated on 10/24/14. Only the dates had been changed. At 10:00 a.m. on 11/06/14 these situations were discussed the DON, the administrator, and Employee #76, a registered nurse supervisor. The administrator acknowledged the facility was aware of problems and they were starting a restorative program. The quality assurance committee had addressed the issue and plans were in place to, roll out a whole new system.",2017-11-01
6781,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-11-06,282,D,1,0,1Q9011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and record review, the facility failed to implement care and services as directed by the residents care plan for one (1) of six (6) records reviewed. Resident #133's care plan directed staff to follow physician's orders [REDACTED].#133. Facility census: 145. Findings include: a) Resident #133 Observation of the resident at 1:40 p.m. on 11/03/14 found her scalp was covered with bright red, inflamed, raised patches of skin covered with patches of dry scaly, silver patches of skin. The resident said she had psoriasis and her head was constantly itching. It drives me crazy. When asked if she was receiving treatment she stated, I am supposed to be. She said she did not think facility staff were washing her hair as often as they should be but she was unsure as to how often she should be receiving treatments. Review of the resident's nursing notes found the following information: -10/26/14 New orders for [MEDICATION NAME] 2% shampoo every MON/WED/FRI (Monday, Wednesday and Friday) . -10/29/14. (typed as written) On assessment of skin with DCD (director of care delivery), psoriasis plaques continue to cover almost entire body from head to toe. Topical treatments in place. Noted head to include posterior occiput covered sporadically over head with white patches of psoriasis which attached firmly to scalp. After cleaning scalp well with wound cleanser and using comb to gently comb hair, most of psoriasis white patches of skin removed from head. Patient denies pain. Patient stated she did not get a bath on the 26th nor did she get her hair washed. DCD aware. Phoned Dr. (name of physician) for update. Left message to return my call. Message left for POA (power of attorney). -10/30/14, Plaque psoriasis covers most of her body .multiple areas on the back and bilateral thighs. Scalp is covered entirely. Does receive embrel for the psoriasis. Also receives [MEDICATION NAME] for the itching . Further review of the treatment administration record (TAR) on 11/03/14 at 2:30 p.m., found the orders for the [MEDICATION NAME] 2% shampoo was added to the TAR on Monday, 10/27/14. The treatment was not initialed as being administered on Monday, 10/27/14; Wednesday, 10/29/14; or Friday, 10/31/14. The director of nursing (DON) was interviewed on 11/03/14 at 2:45 p.m. She provided copies of the TAR and acknowledged the resident did not receive the [MEDICATION NAME] 2% shampoo to the scalp as ordered. Prior to the order for the [MEDICATION NAME] shampoo, the resident's TAR reflected the resident was to have her scalp washed with Selson Blue, weekly. The DON acknowledged the TAR had not been initialed for the entire month of October, 2014 to indicate the treatment was provided. Review of the October, 2014 bathing schedule with the DON found the resident was to receive showers on Mondays and Thursdays and the resident had only received one shower on 10/12/14 during the entire month of October, 2014. The DON also confirmed the resident's scheduled shower days of Mondays and Thursdays did not correlate with the treatment of [REDACTED]. When asked why the nurse used a comb and wound cleanser in an attempt to remove the psoriasis when an order was already in place for the [MEDICATION NAME] shampoo to be applied, she stated, That was not a good idea. Continued review of the medical record on 11/03/14 found a care plan, created on 03/11/13 which addressed, Rash at scalp related to Psoriasis. The goal related to the problem, created on 03/11/14 was, Will show continued signs of healing. Approaches included, Administer treatment per physician orders, follow up care with physician as ordered, and Report evidence of infection such as purulent drainage, swelling localized heat, increased pain, etc. Notify physician prn (as needed).",2017-11-01
6782,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-11-06,309,D,1,0,1Q9011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, and staff interview, the facility failed to ensure a resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well -being, in accordance with the comprehensive assessment and plan of care. Resident #133 was diagnosed with [REDACTED]. The facility obtained a physician's orders [REDACTED]. The facility also failed to follow their care plan for treatment of [REDACTED]. Resident identifier: #133. Facility census: 145. Findings include: a) Resident #133 Observation of the resident at 1:40 p.m. on 11/03/14 found her scalp was covered with bright red, inflamed, raised patches of skin covered with patches of dry scaly, silver patches of skin. The resident said she had psoriasis and her head was constantly itching. It drives me crazy. When asked if she was receiving treatment she stated, I am supposed to be. She said she did not think facility staff were washing her hair as often as they should be but she was unsure as to how often she should be receiving treatments. Review of the resident's nursing notes found the following information: -10/26/14 New orders for [MEDICATION NAME] 2% shampoo every MON/WED/FRI (Monday, Wednesday and Friday) . -10/29/14. (typed as written) On assessment of skin with DCD (director of care delivery), psoriasis plaques continue to cover almost entire body from head to toe. Topical treatments in place. Noted head to include posterior occiput covered sporadically over head with white patches of psoriasis which attached firmly to scalp. After cleaning scalp well with wound cleanser and using comb to gently comb hair, most of psoriasis white patches of skin removed from head. Patient denies pain. Patient stated she did not get a bath on the 26th nor did she get her hair washed. DCD aware. Phoned Dr. (name of physician) for update. Left message to return my call. Message left for POA (power of attorney). -10/30/14, Plaque psoriasis covers most of her body .multiple areas on the back and bilateral thighs. Scalp is covered entirely. Does receive embrel for the psoriasis. Also receives [MEDICATION NAME] for the itching . Further review of the treatment administration record (TAR) on 11/03/14 at 2:30 p.m., found the orders for the [MEDICATION NAME] 2% shampoo was added to the TAR on Monday, 10/27/14. The treatment was not initialed as being administered on Monday, 10/27/14; Wednesday, 10/29/14; or Friday, 10/31/14. The director of nursing (DON) was interviewed on 11/03/14 at 2:45 p.m. She provided copies of the TAR and acknowledged the resident did not receive the [MEDICATION NAME] 2% shampoo to the scalp as ordered. Prior to the order for the [MEDICATION NAME] shampoo, the resident's TAR reflected the resident was to have her scalp washed with Selson Blue, weekly. The DON acknowledged the TAR had not been initialed for the entire month of October, 2014 to indicate the treatment was provided. Review of the October, 2014 bathing schedule with the DON found the resident was to receive showers on Mondays and Thursdays and the resident had only received one shower on 10/12/14 during the entire month of October, 2014. The DON also confirmed the resident's scheduled shower days of Mondays and Thursdays did not correlate with the treatment of [REDACTED]. When asked why the nurse used a comb and wound cleanser in an attempt to remove the psoriasis when an order was already in place for the [MEDICATION NAME] shampoo to be applied, she stated, That was not a good idea. Continued review of the medical record on 11/03/14 found a care plan, created on 03/11/13 which addressed, Rash at scalp related to Psoriasis. The goal related to the problem, created on 03/11/14 was, Will show continued signs of healing. Approaches included, Administer treatment per physician orders, follow up care with physician as ordered, and Report evidence of infection such as purulent drainage, swelling localized heat, increased pain, etc. Notify physician prn (as needed). b)Resident #146 Resident #146 was not provided services related to a wound on the resident's scalp. The Resident had been referred to a dermatologist, for consultation concerning condition related to her scalp. The dermatologist was never seen by Resident #146. On 11/05/14 at 8:50 a.m., review of nurse progress note dated 08/11/14, revealed Appt with Dr. Karr on 8-27-14 @ 10:00 A.M. POA Jenny(NAME)aware. Interview with director of nursing (DON) revealed Resident #146 was referred to a Dermatologist for issues related to her scalp. Results of the consultation were requested at the time of interview. On 11/05/14 at 12:20 p.m., the resident's records from the hospital were obtained. The hospital admission information, dated 10/24/14 was reviewed. The documentation indicated there was a wound located on top of the resident's head with moderate thick purulent drainage. No measurements were recorded. Several photos, taken upon admission were included in the documentation. They showed the wound covered almost the entire top portion of the resident's head. Observation of the photos of the scalp revealed crusted, thickened scab layers covering the top of the resident's head, with matted knotted hair growing through it. Hospital wound care documentation, dated 10/25/14, the day after admission, revealed the wound on top of resident's head had a large amount of thick purulent drainage with noted improvement. The photo revealed many of the previous crusted scab layers were no longer present. On 11/06/14 at 10:25 a.m., an interview was conducted with Employee #117, registered nurse (RN) treatment nurse, concerning Resident #146's scalp and the missed dermatologist appointments. The treatment nurse stated the first time Resident #146's dermatologist appointment was missed was because the resident was admitted to the hospital. The treatment nurse stated, The second appointment was missed because I failed to write the order when I rescheduled it, and I forgot to enter it in the appointment log book, so it was missed. The treatment nurse confirmed it was her error that Resident #146 was not seen by the dermatologist for the condition of her scalp. At 10:45 a.m. on 11/06/14, an interview was conducted with the DON. The DON said, At one point we were treating her (Resident #146)for psoriasis. In August, when the new company took over, I did the body audit and saw it was a dry area that appeared to be attached. I did not know if it was a tumor or mass and instructed my staff not to scrape at it. I discussed it with the facility physician here and the resident was referred to a dermatologist. Our physician here does not usually refer them, so there was a concern. The first appointment was 08/27/14 but the resident ended up in the hospital. The second appointment was 09/24/14 and the order was not written, so it was missed. When asked if the DON thought there had been a delay in care, the DON replied, I agree there was a delay in care, partly because she was in and out of the hospital due to dysfunctional G tube issues. c) Resident #13 Resident #13 was not promptly provided services for skin breakdown around her gastrostomy tube (G tube). On 11/04/14 at 2:15 p.m., accompanied by the DON, an observation was made of Resident #13's feeding tube insertion site. The DON removed the split gauze dressing used to cover the site. The site was excoriated and had two (2) small open areas. One (1) at 7:00 o'clock and one (1) at 1:00 o'clock. There was wet bloody drainage noted on the gauze dressing. The DON disposed of the soiled dressing and stated she would get the resident's nurse to apply a clean dressing. When asked about the excoriation and open areas, the DON said she would have to check on the treatment for [REDACTED]. Review of the resident's medical records, on 11/05/14 at 5:10 p.m., revealed no entry about replacing the split gauge dressing around the G tube on 11/04/14. There was also no documentation regarding the excoriation and small open areas around the feeding tube insertion site. No evidence was found that the physician was notified of these areas. The record contained only a late entry referencing the initial dressing change the nurse did at 9:00 a.m. on 11/04/14. On 11/05/14 at 5:33 p.m., the DON was asked what had been done about the resident's excoriation and open areas. The DON said she thought the floor nurse had taken care of it. The DON was informed that the medical record contained only a late entry about the initial dressing which was applied at 9:00 a.m. on 11/04/14. The DON said she would get the treatment nurse to get an order to address it. Review of the medical record, on 11/06/14 at 2:12 p.m. revealed a nursing progress note, dated 11/05/14 at 19:07 p.m. (7:07 p.m.), by the treatment nurse. It said, On assessment noted G site very red with some pinpoint excoriation surrounding entire G site extending outward 2 cm. Old dark green drainage noted on old split sponge. No blood noted. No foul odor detected Phone Dr. Rahim and received new orders for G-site treatment .Order faxed to pharmacy. Staff aware of new orders. The resident's excoriation and open areas were observed by the DON at 11/04/14 at 2:15 p.m. the physician was not notified or new orders obtained regarding skin condition surrounding resident's G tube until 11/05/14 at 7:07 p.m. This was more than 24 hours after the areas were observed by the DON.",2017-11-01
6783,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-11-06,312,D,1,0,1Q9011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL's) received the care and services necessary to maintain good grooming and personal hygiene. Three (3) of five (5) residents, dependent upon staff for bathing, did not receive showers as scheduled and no efforts were made to determine if showers were offered. Resident identifiers: #28, #133 and #146. Facility census: 145. Findings include: a) Resident #28 An interview with the resident, at 9:00 a.m. on 11/03/14 revealed the resident did not always receive her showers as scheduled. She said her shower days were supposed to be Tuesdays and Fridays. She stated, They try to talk me out of my showers but I tell them I want my shower because two showers a week isn't enough anyway. Review of the last minimum data set (MDS), an annual, with an assessment reference date (ARD) of 08/12/14 found the resident was totally dependent upon staff for personal hygiene and bathing, in Section (G) entitled, functional status. Review of section (E), entitled, behavior, found the resident had not rejected care during the assessment reference period. Review of the resident's bathing schedule with the director of nursing (DON) on 11/03/14 at 1:54 p.m. found the resident had eight (8) opportunities to receive showers in August, 2014 and she received only four (4) showers. In September, 2014 the resident had nine (9) opportunities to receive showers and she received only six (6) showers. During October, 2014 the resident had eight (8) opportunities to receive showers and she received only four (4) showers. The DON stated the resident could have refused to take a shower but she was unable to provide any evidence of any refusals of care or showers. The DON verified the nursing assistant (NA) should have documented refusals of showers if this behavior had occurred. b) Resident #133 Observation of the resident at 1:40 p.m. on 11/03/14 found her scalp was covered with bright red, inflamed, raised patches of skin covered with patches of dry scaly, silver patches of skin. The resident said she had psoriasis and her head was constantly itching. It drives me crazy. When asked if she was receiving treatment she stated, I am supposed to be. She said she did not think facility staff were washing her hair as often as they should be but she was unsure as to how often she should be receiving treatments. Review of the resident's nursing notes found a new order dated,10/26/14 ,for [MEDICATION NAME] 2% shampoo to be applied every Monday, Wednesday and Friday. This order was placed on the resident's treatment administration record (TAR) for the month of October, 2014. Prior to receiving the [MEDICATION NAME] shampoo, the resident had orders for Selson Blue to be used weekly. Administration of the Selson Blue was also placed on the TAR for the month of October, 2014. Review of the treatment administration record with the director of nursing (DON) on 11/03/14 at 2:45 found no evidence the [MEDICATION NAME] shampoo or the Selsen blue was being applied to the resident's scalp as directed. Further review of the October, 2014 bathing schedule with the DON at 2:45 p.m. on 11/03/14 found the resident was to receive showers on Mondays and Thursdays and the resident had only received one shower on 10/12/14 during the entire month of October, 2014. The DON also confirmed the resident's scheduled shower days of Mondays and Thursdays did not correlate with the treatment of [REDACTED]. The most recent MDS, a quarterly, with an ARD of 08/27/14 found the resident was totally dependent upon staff for bathing, Section (G), entitled functional status and the resident had not refused care, Section (E), entitled behavior, during the reference assessment period. c) Resident #146 (closed record) Review of the resident's last MDS with an ARD of 10/24/14, a discharge assessment, (Section G) found the resident was totally dependent upon staff for bathing. Further review of the resident's shower schedule with the DON at 12:08 p.m. on 11/05/14 found the following: --During the month of September, 2014 the resident had nine (9) opportunities to receive a shower and she only received four (4) showers. --During the month of October, 2014, the resident had six (six) opportunities to receive a shower, before her discharge from the facility on 10/24/14, and she only received one (1) shower on 10/21/14. The DON confirmed the NA did not document any refusals of showers for this resident.",2017-11-01
6784,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-11-06,322,D,1,0,1Q9011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, policy review, review of the U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality guidelines for enteral nutrition titled, Medication Administration in the American Society for [MEDICATION NAME] and Enteral Nutrition (A.S.P.E.N.) practice recommendations, and staff interview, the facility failed to ensure two (2) of five (5) residents reviewed with feeding tubes received care and services to prevent complications. The facility failed to check placement of gastrostomy tubes prior to administering medication, failed to mix dried crushed medication powder in sterile water prior to administration, and crushed [MEDICATION NAME] coated medication which should not be administered through an enteral tube. Resident identifiers: #133 and #13. Facility census: 145 Findings include: a) Resident #133 On 11/04/14 at 4:03 p.m. Employee #50, registered nurse (RN), was observed administering medications via Resident #133's gastrostomy tube (G tube). Resident #133 was positioned in bed at 45 degrees. The nurse stated that sometimes the tube gets clogged. She explained the resident had .the old type of tube made like a foley catheter, it is bad to get clogged up. The tube was not checked for placement prior to giving the medication. The plunger was removed from the syringe, and the syringe was placed on the end of the G tube to act as a funnel. The tube was flushed with 15 cubic centimeters (cc) of water via gravity prior to giving the medication, thereby moistening the inside of the syringe. The medication Carbidope-[MEDICATION NAME] 25/100 milligrams (mg) was finely crushed to a dry powder and poured into the syringe, then water was added into the syringe. There were clumps of dry powder floating in the syringe and sticking to the bottom and sides of the syringe. The nurse flushed the syringe with warm water. Promod 30 milliliters(ml), a liquid protein, was poured into the syringe, and the G tube was flushed with water. b) Resident #13 On 11/04/14 at 4:15 p.m., Employee #50, registered nurse (RN), was observed administering medications via Resident #13's G tube. The RN crushed [MEDICATION NAME] 5 mg and crushed [MEDICATION NAME] coated Calcium Vitamin D 600/400U and placed them in separate cups. The RN then added warm water to the crushed Calcium Vitamin D. While stirring it she stated .coating on the medicine clogs the tube if it's not dissolved in warm water first, so you can get the coating off. The crushed [MEDICATION NAME] powder was dropped down into the syringe then water was added into the syringe. There were clumps of dry powder floating in the syringe and sticking to the bottom and sides of the syringe. Syringe was flushed with water a second time. The Calcium Vitamin D 600/400U was given after the nurse pulled out a chunk of undissolved substance from the medicine cup. The tube was then flushed with water. c) On 11/06/14 at 3:45 p.m., interview with the director of nursing (DON) and review of the facility's policy for Medication Administered through an Enteral Tube #14 revealed the nurse was to check the placement of the G tube prior to administering medication, and #5.d. indicated [MEDICATION NAME] coated medications should not be given through a G tube. Interview with the DON confirmed the nurse should have checked placement first before giving medication, the powder should have been mixed with water and dissolved before administering, and the nurse should not have given crushed [MEDICATION NAME] coated medication. d) The U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality guidelines for enteral nutrition were reviewed. The guideline titled Medication Administration in the American Society for [MEDICATION NAME] and Enteral Nutrition (A.S.P.E.N.) #3 of the practice recommendations states, . Liquid dosage forms should be used when available and if appropriate. Only immediate-release solid dosage forms may be substituted. Grind simple compressed tablets to a fine powder and mix with sterile water. Open hard gelatin capsules and mix powder with sterile water.",2017-11-01
6785,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-11-06,441,F,1,0,1Q9011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, family interview, facility record review, and policy review, the facility failed to maintain an infection control program to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. The facility failed to perform surveillance and investigation to identify and control outbreaks and cross-contamination of infections related to nine (9) facility acquired Clostridium difficile (C-diff) infections between 09/23/14 and 10/29/14; failed to identify areas of direct/indirect transmission of infectious agents through a contaminated intermediate object; failed to identify staff roles and responsibilities for implementation of the program; failed to utilize personal protective equipment (PPE) when indicated; failed to implement hand hygiene practices consistent with accepted standards of practice; failed to educate staff and families of transmission based precautions; and failed to post signage on one (1) of fifteen (15) rooms requiring special precautions. Housekeeping staff failed to utilize gloves when cleaning an isolation room and contaminated a cart with soiled gloves; nursing assistants failed to utilize gloves when touching inanimate objects in isolation rooms, and failed to utilize adequate hand hygiene prior to exiting rooms. Administrative staff indicated a lack of awareness of roles of the infection control program, resulting in a failure to educate staff and families of infection control practices. These issues had the potential to affect all residents. Facility census: 145. Findings include: a) On 11/05/14, review of the isolation list dated 11/03/14, revealed nineteen (19) residents in fifteen (15) rooms, required isolation precautions. Further review of the infection control log for October 2014 revealed nine (9) residents with in-house acquired Clostridium difficile (C-diff) from 09/23/14 - 10/29/14. Random observations, completed on 11/05/14 and 11/06/14 revealed the following: -- During an observation on 11/05/14 at 9:30 a.m., Employee #68, a nursing assistant (NA), picked up linens and person clothing in room ASC-2 without utilizing personal protective equipment (PPE), and did not wash her hands prior to exiting the room. An interview with the NA revealed Resident #50 required precautions related to a [DIAGNOSES REDACTED]. -- An observation on 11/05/14 at 11:00 a.m., revealed Employee #79, (NA), assisted Resident #126 with activities of daily living (ADLs). The NA did not utilize PPE when turning the faucet on and off, and leaned against the sink with her forearm resting on the basin. Without sanitizing her hands, she placed personal items in plastic bags, and removed them as the resident needed them. These included lipstick, toothbrush, toothpaste, and a hair brush. Additionally, she removed a drinking cup from the over-bed table, utilized the ice chest and returned the cup to the room. Employee #79 failed to utilize hand hygiene. A sign on the door indicated the resident required precautions. Review of the isolation list provided by the infection control nurse, revealed Resident #126 required contact precautions related to extended spectrum beta lactalose (ESBL), a bacteria resistant to treatment. -- At 11:11 a.m. on 11/05/14, an observation noted Employee #113, a nursing assistant, passing ice to residents in room G15. While adding water to the drinking cups, the NA turned the bathroom faucet on and off without utilizing a barrier and did not sanitize her hands. During another observation at 11:24 a.m., the NA carried a drinking cup from room G15 across the hall to room G14, obtained water from the bathroom faucet, and returned the cup to room G14. Again, the NA did not utilize a barrier when turning the faucets on and off, and did not sanitize her hands. -- During a lunch meal observation, on 11/05/14 at 12:15 p.m., Employee #72 (NA) removed a lunch tray from room ASPC. According to the infection control log, Resident #50 required precautions related to carbapenum-resistant [MEDICATION NAME] (CRE). Another observation at 12:23 p.m., revealed Employee #72 entered room A1 (Resident #105), placed a baggie containing a sandwich on the over-bed table, picked it up again and removed the sandwich. The NA then repositioned the table, turned on the light, utilized hand sanitizer and exited the room. He did not utilize gloves while handling inanimate objects. Review of the infection control log revealed Resident #105 required contact precautions related to CRE, ESBL and MRSA (methicillin-resistant staphylococcus aureus). -- A random observation, on 11/05/14 at 12:05 p.m., revealed a visitor at the bedside of Resident #20, without PPE. An interview the with individual revealed the person was not the resident's legal representative. The family member related she only assisted him with turning and positioning. Upon further inquiry, she related staff had not provided education related to wearing a gown when providing direct care. Review of the infection control log revealed the resident required contact precautions related to MRSE (methicillin resistant staphylococcus epidermis), CRE, and VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]). -- On 11/05/14 at 9:45 a.m., an observation revealed Employee #74 swept room A6 with a Swifter-type mop head. Upon completion, the housekeeper removed the pad without utilizing gloves. -- An observation of housekeeping services on 11/05/14 at 9:50 a.m., revealed Employee #111 cleaning room B14 and attired with a gown and gloves. The housekeeper related special precautions were required, but did not know why. The residents were not present in the room during the cleaning process. The housekeeper cleaned the bed, then returned to the housekeeping cart outside of the doorway. Without removing gloves and/or utilizing hand hygiene, Employee #111 opened the top door of the cart and rewet her cleaning rag. She returned to the room and continued to clean the bed and nightstand. With the same contaminated gloves, the housekeeper repositioned the bedside curtain, then held pillows in place on the over the bed table, using the palm of her gloved hand. She exited the room, removed her gloves, donned new gloves without sanitizing her hands, and again rewet the cleaning rag and cleaned the wall behind the night stand. She again exited the room with her PPE in place to access the housekeeping cart. Employee #111 removed the soiled mop head, and opened a door on the side of the cart which contained mop heads. With the same soiled gloves, the housekeeper obtained a new mop head for the Swifter-type mop from the bucket and with multiple twisting and turning motions, wrung it out in the water containing all the clean mop heads. Additionally, at 10:00 a.m. on 11/05/14, Employee #111 picked up a bag of soiled linen from the floor of room B14 and requested Employee #139, a nursing assistant, take it to the soiled linen room. Without utilizing gloves, the NA carried the soiled linens to the utility room. Review of the infection control log, dated 11/03/14, precautions were required for Clostridium difficile (C-diff). In an interview with the director of nursing and infection control nurse on 11/05/14 at 5:00 p.m., they confirmed the [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]icile can survive in the environment, e.g., on floors, bed rails or around toilet seats in its spore form for up to six months. Rigorously cleaning the environment removes [DIAGNOSES REDACTED]icile spores, and can help prevent transmission of the organism. -- Another observation on 11/05/14 at 10:35 a.m., revealed Employee #42 (housekeeping) cleaning room G7 without utilizing gloves. She was picking up debris from the floor. An interview with the employee revealed she believed the resident required precautions for[DIAGNOSES REDACTED]icile, but related gloves were not required because she did not take care of the resident. The housekeeper did not sanitize her hands when exiting the room. She obtained a rag and without utilizing gloves, cleaned the sweeper which was sitting outside the room of G7. The housekeeper donned gloves and cleaned room G6 with a Swifter-type mop. Upon completion, she removed her gloves, and without gloves removed the soiled mop head. Employee #42 returned to room G7, ran the electric sweeper. Upon completion, she returned to room G6 to sweep that room. At no time during the process did the housekeeper sanitize her hands. -- An interview with Employee #156 (NA) revealed staff were not always aware of the reason a resident required isolation, and indicated staff should always wash hands with soap and water, even after taking gloves off. She said hand sanitizer should not be used in case of spores. Employee #106 (NA), interviewed on 11/05/14 at 4:18 p.m., related she washed her hands upon completion of a task and utilized hand sanitizer as she exited the room. She also indicated staff were unsure why a resident was on precautions and needed to be careful. -- During a random observation at 11/05/14 at 4:30 p.m., the doorway of Room G12 had an over the door container with isolation protective equipment. No sign was present to indicate someone should check with the nurse prior to entering the room. -- On 11/05/14 at 4:30 p.m., Employee #14 entered room G7 with no personal protective equipment. She exited the room, obtained a clear plastic bag, and upon re-entry assisted Resident #26 place soiled clothing items in the bag. The NA carried them to the soiled utility and did not sanitize her hands until she passed the nurses' station to another soiled utility room on the next hall. The resident returned to the hallway and entered room #G5 to assist the resident in bed B. Upon completion, she washed her hands for a count of four (4) seconds. During an interview with the NA at 4:38 p.m., she confirmed she had not utilized gloves when caring for Resident #26 and related she did not know the protocol for isolation precautions. With further inquiry, she related she should have washed her hands for twenty (20) seconds. The NA confirmed she did not utilize PPE unless prepared to provide direct care. b) Review of the infection control policy related to contact precautions revealed staff would increase efforts to determine the origin of transmission of the disease, provide additional education to staff and families, and obtain a consult from specialists. An interview with the infection control nurse, Employee #181 on 11/05/14 from 4:51 p.m. through 5:20 p.m., revealed she identified the[DIAGNOSES REDACTED] outbreak on 10/31/14, at which time she contacted the health department. She indicated she had not yet reported the outbreak because the health department nurse had not returned her phone call. Employee #181 further related contact occurred routinely with the health department due to the facility's history of infectious diseases. The director of nursing (DON) joined the interview with Employee #181 at 4:57 p.m. She and Employee #181 confirmed the potential for cross contamination related to staff's failure to properly utilize PPE and hand hygiene. They verified Employee #68, #79, #113, #74, #111, #42 and #14 posed risks of transmitting disease and infection related to nonadherence to infection control protocols and confirmed staff did not adhere to strict compliance to minimize the spread of MDROs to other susceptible individuals. An interview, on 11/06/14 at 11:30 a.m., confirmed the health department was not yet aware of the current number of in-house acquired cases of[DIAGNOSES REDACTED]. The nurse related the health department would probably report to the state level, would provide the facility with a tool kit and keep in touch until cases stop or slow down, and may do a sight visit. Another interview with the infection control nurse (Employee #181) revealed she did not provide education to the staff. She indicated she was only responsible for nursing, and assumed the department head would have in-serviced their departments when educated. With further inquiry she confirmed she was responsible for the infection control program, and acknowledged the program would include all aspects of the facility. She related the facility had not requested a consultation of a specialist other than the routine check with the health department. When questioned about identification of infections, she related she completed a track and trend at the end of each month, however no trending was noted for October 2014, at which time facility acquired[DIAGNOSES REDACTED] escalated. Employee #127, staff development coordinator, during an interviewed on 11/06/14 at 3:45 p.m., revealed the facility had not identified housekeeping practices as an environmental contaminate in relation to the transmission of disease and infection. She further related staff had not considered curtains and pillows as possible contaminates. Employee #127 related the practice was identified after being brought to the facility's attention on 11/05/14. She confirmed she had not educated staff other than nursing, and had not identified a need to educate other departments. During an interview on 11/06/14 at 2:00 p.m., the administrator related a new system was put in place two (2) weeks ago, with actual rounds, hands on, with praise and teaching. With further inquiry, he acknowledged the facility had not yet started to monitor staff for compliance with infection control protocols. Additionally, observation of incontinence care in room DSPC, on 11/06/14 at 10:30 a.m., revealed the room contained two (2) beds and had very limited space to maneuver without touching inanimate objects. Set-up required staff removed PPE on the side of the room opposite of the doorway, and the far side of the resident's bed. The administrator confirmed the room set up was not good because precautions were required for[DIAGNOSES REDACTED] and posed a risk for cross-contamination.",2017-11-01
6786,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-11-06,514,D,1,0,1Q9011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure a residents medical record was accurate. A registered nurse documented a resident's treatment as having been provided on the treatment administration record (TAR) when the treatment had not been administered. This was true for one (1) of five (5) medical records reviewed. Resident identifier: #133. Facility census: 145. Findings include: a) Resident #133 Review of the resident's treatment administration record (TAR) with Employee #50, a registered nurse (RN) and the director of nursing (DON) at 2:30 p.m. on 11/13/14 found RN #50 had initialed the TAR indicating she had provided the following treatment, Cleanse entire back, buttock, bilateral groin folds and abd. (abdomen) fold with H2O (water) and soap, pat dry, apply [MEDICATION NAME] 2% cream (BID) twice a day x 14 days and re-evaluate. RN #50 stated she had planned to apply the treatment but the cream was locked in the treatment cart and she did not have a key to open the cart.",2017-11-01
6787,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-11-06,520,F,1,0,1Q9011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of the infection control logs, policy reviews and observations, the quality assessment and assurance (QAA) committee failed to identify and address quality deficiencies of which they were aware or should have been aware. These practices had the potential to affect all residents. In the areas of resident behavior and facility practices, the (QAA) failed to identify a resident had not received showers and treatment to her scalp for psoriasis. After a transfer to the hospital, the facility was notified by the hospital of the condition of the scalp and hair when the resident arrived at the hospital. After notification of substandard quality of care by a local hospital, the facility reported and investigated the alleged allegation of neglect. In the area of quality of care, the facility failed to ensure a resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well -being, in accordance with the comprehensive assessment and plan of care. Resident #133 was diagnosed with [REDACTED]. The facility obtained a physician's orders [REDACTED]. In the care area of infection control, the facility failed to maintain an infection control program to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. The facility failed to perform surveillance and investigation to identify and control outbreaks and cross-contamination of infections related to nine (9) facility acquired [MEDICAL CONDITIONS] infections between 09/23/14 and 10/29/14; failed to identify areas of direct/indirect transmission of infectious agents through a contaminated intermediate object; failed to identify staff's rolls and responsibilities for implementation of the program; failed to utilize personal protective equipment (PPE) when indicated; failed to implement hand hygiene practices consistent with accepted standards of practice; failed to educate staff and families of transmission based precautions; and failed to post signage on one (1) of fifteen (15) rooms requiring special precautions. A housekeeper failed to utilize gloves when cleaning an isolation room, nursing assistants failed to utilize gloves when touching inanimate objects in isolation rooms, and failed to utilize adequate hand hygiene prior to exiting the rooms. Administrative staff was unsure of rolls related to the infection control program, resulting in a failure to educate staff and families of infection control practices. Facility census: 145. Findings include: a) Quality of Care The facility failed to ensure Resident #133 received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well -being, in accordance with the comprehensive assessment and plan of care. Resident #133 was diagnosed with [REDACTED]. The facility obtained a physician's orders [REDACTED]. The facility also failed to follow their care plan for treatment of [REDACTED]. Observation of the resident at 1:40 p.m. on 11/03/14 found her scalp was covered with bright red, inflamed, raised patches of skin covered with patches of dry scaly, silver patches of skin. The resident said she had psoriasis and her head was constantly itching. It drives me crazy. When asked if she was receiving treatment she stated, I am supposed to be. She said she did not think facility staff were washing her hair as often as they should be but she was unsure as to how often she should be receiving treatments. Review of the resident's nursing notes found the following information: -10/26/14 New orders for [MEDICATION NAME] 2% shampoo every MON/WED/FRI (Monday, Wednesday and Friday) . -10/29/14. (typed as written) On assessment of skin with DCD (director of care delivery), psoriasis plaques continue to cover almost entire body from head to toe. Topical treatments in place. Noted head to include posterior occiput covered sporadically over head with white patches of psoriasis which attached firmly to scalp. After cleaning scalp well with wound cleanser and using comb to gently comb hair, most of psoriasis white patches of skin removed from head. Patient denies pain. Patient stated she did not get a bath on the 26th nor did she get her hair washed. DCD aware. Phoned Dr. (name of physician) for update. Left message to return my call. Message left for POA (power of attorney). -10/30/14, Plaque psoriasis covers most of her body .multiple areas on the back and bilateral thighs. Scalp is covered entirely. Does receive embrel for the psoriasis. Also receives [MEDICATION NAME] for the itching . Further review of the treatment administration record (TAR) on 11/03/14 at 2:30 p.m., found the orders for the [MEDICATION NAME] 2% shampoo was added to the TAR on Monday, 10/27/14. The treatment was not initialed as being administered on Monday, 10/27/14; Wednesday, 10/29/14; or Friday, 10/31/14. The director of nursing (DON) was interviewed on 11/03/14 at 2:45 p.m. She provided copies of the TAR and acknowledged the resident did not receive the [MEDICATION NAME] 2% shampoo to the scalp as ordered. Prior to the order for the [MEDICATION NAME] shampoo, the resident's TAR reflected the resident was to have her scalp washed with Selson Blue, weekly. The DON acknowledged the TAR had not been initialed for the entire month of October, 2014 to indicate the treatment was provided. Review of the October, 2014 bathing schedule with the DON found the resident was to receive showers on Mondays and Thursdays and the resident had only received one shower on 10/12/14 during the entire month of October, 2014. The DON also confirmed the resident's scheduled shower days of Mondays and Thursdays did not correlate with the treatment of [REDACTED]. When asked why the nurse used a comb and wound cleanser in an attempt to remove the psoriasis when an order was already in place for the [MEDICATION NAME] shampoo to be applied, she stated, That was not a good idea. Continued review of the medical record on 11/03/14 found a care plan, created on 03/11/13 which addressed, Rash at scalp related to Psoriasis. The goal related to the problem, created on 03/11/14 was, Will show continued signs of healing. Approaches included, Administer treatment per physician orders, follow up care with physician as ordered, and Report evidence of infection such as purulent drainage, swelling localized heat, increased pain, etc. Notify physician prn (as needed). At 10:00 a.m. on 11/06/14 the above issues were discussed with the administrator, director of nursing (DON), and Employee #76 a registered nurse (RN) supervisor to determine if the facility had addressed the above issues in their QAA meetings. In reference to Resident #146, the administrator stated he became aware of the situation after he was called by the hospital. He stated that he and his admissions coordinator traveled to the hospital to look at the resident and the hospital records. He stated he saw a, bloody head, in the pictures taken by the hospital but this was after the hospital provided treatment. He stated he though the resident had what looked like a [DIAGNOSES REDACTED] on her scalp. The DON stated she had looked at the residents scalp around the, middle of August. She stated the area to the scalp was dry and raised. I did not do anything because the area was attached to her scalp. She said the treatment nurse should have let the doctor know and she believed that occurred because an appointment was scheduled with the dermatologist on 08/27/14. The resident did not keep this appointment because she was sent out to the hospital. A second appointment was scheduled for 09/24/14 but we did not get the order transcribed so the resident missed this appointment. The administrator stated, That is where we dropped the ball, yes, there was a delay in care but with what was on her head we were not prepared to do anything for it. When questioned about the residents failure to receive showers the DON stated, every residents shower scheduled was revised in an attempt to improve, we want our process to be when a resident refuses a shower we want the nurse notified. The nursing assistant needs to put it in the Kiosk. Employee #76 stated, We are not a 100% but we are working on it. The issues with Resident #133 were also discussed. The DON said the resident had been out to see her dermatologist and, we had already determined she had an issue also. She felt the resident had refused treatment / showers and the facility had failed to document the refusals. The DON was unaware the treatments to her scalp had not been provided as ordered. b) Infection control On 11/05/14, review of the isolation list dated 11/03/14, revealed nineteen (19) residents in fifteen (15) rooms, required isolation precautions. Further review of the infection control log for October 2014 revealed nine (9) residents with in-house acquired [MEDICAL CONDITIONS] from 09/23/14 - 10/29/14. Random observations, completed on 11/05/14 and 11/06/14 revealed the following: -- On 11/05/14 at 9:45 a.m., an observation revealed Employee #74 swept room A6 with a swifter type mop head. Upon completion, the housekeeper removed the pad without utilizing gloves. -- On 11/05/14 at 9:50 a.m., revealed Employee #111 (housekeeping) cleaning room B14 and was attired with a gown and gloves. The housekeeper related special precautions were required, but did not know why. The residents were not present in the room during the cleaning process. The housekeeper cleaned the bed, then returned to the housekeeping cart outside of the doorway. Without removing gloves and/or utilizing hand hygiene, Employee #111 opened the top door of the cart and rewet her cleaning rag. She returned to the room and continued to clean the bed and nightstand. With the same soiled gloves, the housekeeper repositioned the bedside curtain, then held pillows in place on the over the bed table, using the palm of her gloved hand. She exited the room, removed her gloves, donned new gloves without sanitizing her hands, and again rewet the cleaning rag and cleaned the wall behind the night stand. She again exited the room with her PPE in place to access the housekeeping cart. Employee #111 removed the soiled mop head, and opened a door on the side of the cart which contained mop heads. With the same soiled gloves, the housekeeper obtained a new mop head for the swifter type mop from the bucket and with multiple twisting and turning motions, wrung it out in the water containing all the clean mop heads. Additionally, At 10:00 a.m. on 11/05/14, Employee #111 picked up a bag of soiled linen from the floor of room B14 and requested Employee #139, a nursing assistant, take it to the soiled linen room. Without utilizing gloves, the NA carried the soiled linens to the utility room. Review of the infection control log, dated 11/03/14, precautions were required for [MEDICAL CONDITIONS]. An interview with the director of nursing and infection control nurse on 11/05/14 at 5:00 p.m., they confirmed the [DIAGNOSES REDACTED]. (C. difficile can survive in the environment (e.g., on floors, bed rails or around toilet seats) in its spore form for up to six months. Rigorously cleaning the environment removes [DIAGNOSES REDACTED]icile spores, and can help prevent transmission of the organism.) -- On 11/05/14 at 10:35 a.m., revealed Employee #42 (housekeeping) cleaning room G7 without utilizing gloves. She was picking up debris from the floor. An interview with the employee revealed she believed the resident required precautions for [MEDICAL CONDITION], but related gloves were not required because she did not take care of the resident. The housekeeper did not sanitize her hands when exiting the room. She obtained a rag and without utilizing gloves, cleaned the sweeper which was sitting outside the room of G7. The housekeeper donned gloves and cleaned room G6 with a swifter type mop. Upon completion, she removed her gloves, and without gloves removed the soiled mop head. Employee #42 returned to room G7, ran the electric sweeper. Upon completion, she returned to room G6 to sweep her room. At no time during the process did the housekeeper sanitize her hands. -- On 11/06/14 at 10:30 a.m., revealed the room contained two (2) beds and had very limited space to maneuver without touching inanimate objects. Set-up required staff removed PPE on the side of the room opposite of the doorway, and the far side of the resident's bed. The administrator confirmed the room set up was not good because precautions were required for [MEDICAL CONDITION] and posed a risk for cross-contamination. He confirmed an action plan had not been developed to correct the problem. An interview with the Infection control nurse (Employee #181) revealed she did not provide education to the staff. She indicated she was only responsible for nursing, and assumed the department head would have in-serviced their departments when educated. With further inquiry she confirmed she was responsible for the infection control program, and acknowledged the program would include all aspects of the facility. She related the facility had not requested a consultation of a specialist other than the routine check with the health department. When questioned about identification of infections, she related she completed a track and trend at the end of each month, however no trending was noted for October 2014, at which time facility acquired [MEDICAL CONDITION] escalated. Employee #127, staff development coordinator, during an interviewed on 11/06/14 at 3:45 p.m., revealed the facility quality assurance committee had not identified and addressed housekeeping practices as an environmental contaminate in relation to the transmission of disease and infection. She further related staff had not considered curtains and pillows as possible contaminates. Employee #127 related the practice was identified after being brought to the facility's attention on 11/05/14. She confirmed she had not educated staff other than nursing, and had not identified a need to educate other departments. At 10:00 a.m. on 11/06/14 the above issues were discussed with the administrator, director of nursing (DON), and Employee #76 a registered nurse (RN) supervisor to determine if the facility had addressed the above issues in their QAA meetings. In regards to the infection control program, the DON stated we have been working with our staff on what PPE needs to be worn in the rooms and hand washing. We have had to clarify what staff need to wear when the resident just wants the lights turned or versus providing actual care. The health department calls us every Friday and we have even talked with the, head of the whole state health department to make sure we are addresses the issues. The administrator stated we looked at trending but found no issues. We have ordered [MEDICATION NAME] hand sanitizers and [MEDICATION NAME] paper towel dispensers because we identified an issue with our equipment. Since your visit we have started education again throughout all our departments. During an interview on 11/06/14 at 2:00 p.m., the administrator related a new system was put in place two (2) weeks ago, with actual rounds, hands on, with praise and teaching. With further inquiry, he acknowledged the facility had not yet started to monitor staff for compliance with infection control protocols to ensure the facility met the expected standard of quality.",2017-11-01
6788,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-11-21,225,D,1,0,X1Q611,"Based on a review of the concern log, a review of the reported allegations of abuse and neglect, and staff interview, the facility failed to ensure all allegations of neglect were reported to the required State agencies. A review of five (5) months of concern logs revealed two (2) concerns contained allegations of neglect, which were not reported as required. Resident identifiers: #142 and #146. Facility census: 145. Findings include: a) Resident #142 On 11/18/14 at 4:45 p.m., a review of the concern log and reportable allegations of abuse and neglect logs for June, July, August, September, and October 2014 revealed Resident #142's sister reported a concern on 10/07/14. The concern stated, Sister upset that resident was late for appointment citing that ambulance was called late and resident was inappropriately dressed. The concern log stated nursing was responsible for resolving the issue. Employee #148 (registered nurse) indicated, on 11/18/14 at 5:05 p.m.,she did not report this as an allegation of neglect. b) Resident #146 A review of the concern log and reportable allegations of abuse and neglect log, on 11/18/14 at 4:45 p.m., revealed a concern filed on 10/07/14. The concern stated, Son upset that walker was not moved with resident during room move yesterday and resident fell in the night. Concerned with resident's report this morning that no one answered call light for four hours. On 11/18/14 at 5:10 p.m., Employee #148 said the facility had investigated this issue but did not report it as neglect.",2017-11-01
6789,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-11-21,280,D,1,0,X1Q611,"Based on medical record review and staff interview, the facility failed to revise and/or evaluate the effectiveness of the goals for one (1) of six (6) care plans reviewed. Resident #80's care plan was not revised with realistic achievable goals to reflect the resident's current functional ability. Resident identifier: #80. Facility Census: 145. Findings include: a) Resident #80 On 11/20/14 at 4:30 p.m., a review of Resident #80's care plan revealed the problem: ADL (activity of daily living) resident requires assistance with ADLs due to decreased functional mobility and weakness due to recent hospitalization . The goal was for the resident to do upper-body ADLs with setup assistance daily through the next review period. Section G of the admission minimum data set (MDS), with an assessment reference date (ARD) of 09/10/14, indicated the resident was extensive assistance of two (2). Section G of the 30- day MDS, with an ARD of 10/01/14, also noted the resident required extensive assistance with two (2) person physical assistance. On 11/20/14 at 5:00 p.m., an interview with Employee #158, certified occupational therapy assistant (COTA) revealed she worked with Resident #80 from 09/08/14 to 11/02/14. The COTA said the resident did not progress from the point of requiring maximum assistance in ADLs. Due to this lack of progress, the COTA agreed the resident's current goal was unrealistic. An interview with MDS Employee #194, on 11/20/14 at 5:10 p.m., confirmed the resident's care plan goal was not achieved, even though they worked toward it. Employee #194 agreed the care plan needed revised in this area. She agreed the goal was not attainable or realistic for the resident at this point in time. Employee #194 said the resident's care plan was not due for review again until January 2014.",2017-11-01
6790,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-11-21,323,D,1,0,X1Q611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family interview, observation, and staff interview, the facility failed to ensure the environment for two (2) of six (6) residents was as free as possible of accidents over which the facility had control. Resident #131 sustained multiple falls. She had an alarm mat in place; however, the facility had not ensured the proper functioning of the alarm mat. Resident #142 sustained a fall in her room. The facility had not fully investigated the fall to determine all the potential accident hazards that were in the resident's room. Resident identifiers: #131 and #142. Facility census: 145. Findings include: a) Resident #131 On 11/17/14 at 4:39 p.m., an observation revealed Resident #131 had an alarm mat on the left side of her bed. The bed frame had a box with a cord hanging from it. Employee #112 (assistant director of nursing) came into the room at 4:45 p.m. on 11/17/14, and verified this box was the alarm that was supposed to be connected to the bedside mat. She confirmed the alarm was not connected. Employee #112 tried to reconnect the alarm. The connection on the box had some broken pieces, so the cord to activate the alarm could not be plugged into the alarm box. On 11/18/14 at 11:00 a.m., Employee #150 (medical records clerk) said he had ordered a replacement alarm for Resident #131. He was asked what had happened to the alarm box, and commented, The piece where the electrical cord connected was broken. The medical record review for Resident #13, on 11/17/14 at 3:00 p.m., revealed Resident #131 fell on [DATE], 10/22/14, 10/26/14, 10/27/14, and 11/02/14. The review revealed the falls on 09/29/14, 10/22/14, 10/26/14, 10/27/14, and 11/02/14 all occurred in the resident's room. She fell from her bed onto the floor. A review of the fall notes for the falls that occurred on 10/22/14, 10/26/14, 10/27/14, and 11/02/14 revealed no mention of an alarm mat. The notes also did not mention whether or not it was alarming when staff found the resident on the bedside mat. A fall note on 10/22/14 stated, Check that mat alarm is working properly and turned on. On 11/18/14 at 4:00 p.m., Employee #171 (registered nurse), provided the treatment administration record for Resident #131. A review of the treatment sheets for October and November 2014 revealed the facility had monitored for the placement of the floor mat but did not mention monitoring the functioning of the alarm. On 11/19/14 at 9:00 a.m., the director of nursing said she had no further information regarding this issue. She indicated the facility did not plan to continue using the alarm mat for Resident #131. b) Resident #142 The medical record review for Resident #142, on 11/18/14 at 2:00 p.m., revealed the resident fell in her room on 09/22/14 at 4:45 a.m. The fall note stated, Called to room by CNA (nurse aide) observed resident lying in floor with her head against entry door. Resident was lying on her back. Urine/water was in the floor. Resident alert. Denied any pain in arms, legs, or back. MAE (moves all extremities). Assisted to sitting position. Noted blood coming from left cheek and left ear On 11/17/14 at 2:05 p.m., a confidential interview revealed the lay out of the resident's room made it difficult to get to the bathroom. This interview also revealed that after the resident fell on [DATE], the facility installed a night light in the resident's room due to the family's request. An observation of the resident's room, on 11/18/14 at 9:00 a.m., revealed the resident's roommate was in Bed A, which was the bed closest to the bathroom. Bed A had an air mattress. The motor to the air mattress was hanging on the footboard of the bed. Bed A was located in front of the bathroom door. The door to the bathroom would not open fully. The door was stuck on the air mattress motor. Employee #171 (registered nurse), was interviewed on 11/19/14 at 6:00 p.m. She said she did not see any issues with the way the resident's room was set up. She indicated the facility had not looked at the bathroom door, the way it opened, or that it became stuck on the air mattress motor on Bed A. The facility did not identify these situations after Resident #142 fell on [DATE]. On 11/21/14 at 9:00 a.m., the maintenance supervisor (Employee #3) stated he could move the air mattress motor on Bed A off the footboard and onto the bed frame. He also stated he had provided in-service education to employees on making sure the bathroom door would open fully. He moved Bed A to ensure the bathroom door would open fully.",2017-11-01
6791,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-11-21,465,E,1,0,X1Q611,"Based on observation and staff interview, the facility failed to ensure a safe, functional environment for all residents. Observations in three (3) of six (6) resident rooms revealed the bathroom doors would not open fully due to getting stuck against the footboard of Bed A. Room numbers: A6, F7, and G5. Facility census: 145. Findings include: a) On 11/21/14 at 8:15 a.m., observations in Rooms A6, F7, and G5 revealed the bathroom doors would not open fully due to becoming stuck against the footboard of Bed A. The bathroom door was located in front of Bed A. In room A6, the bathroom door had even less clearance to open fully, because bed A had an air mattress motor at the footboard. At 8:30 a.m. on 11/21/14, the maintenance supervisor accompanied an observation of the rooms, and confirmed the doors to the bathroom in A6, F7, and G5 did not open fully. He moved the air mattress box from the foot board of Bed A in room A6. He said staff should place the air mattress motor box on the bed frame instead of on the footboard of the bed. He also moved the bed over toward the door, to provide more room for the door to the bathroom to open. He indicated he had in-serviced staff on this issue, but the facility had a lot of turnover in staff. He said he had thought about putting down tape on the floor to show staff where Bed A should be positioned.",2017-11-01
7519,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-04-24,224,G,1,0,HZEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview, the facility failed to implement procedures to ensure residents were free of neglect. The facility failed to provide care and services to ensure residents received the correct diet to prevent choking. The facility did not ensure restrictions regarding swallowing were implemented for Resident #142. The resident did not receive a mechanical soft diet as ordered by the physician, but was served a whole hot dog (not ground) on a bun. As a result of being served the incorrect diet, the resident experienced actual harm when she choked and was sent to the hospital. Subsequently, the facility's investigation of the occurrence failed to identify the resident did not receive a mechanical soft diet as ordered. As a result the facility did not implement measures to prevent this from reoccurring for this resident or other residents. Staff gave inconsistent responses regarding what swallowing restrictions were in place upon her return from the hospital. This was true for one (1) of nine (9) sampled residents and had the potential to affect more than an isolated number of residents who received a mechanically altered diet. Fifty-two (52) residents were receiving mechanically altered diets at the time of the survey. Resident identifier: #142. Facility Census: 141. Findings include: a) Resident #142 Review of the resident's medical record found a nursing entry, dated 03/26/14 at 19:21 (7:21 p.m.), noting the resident's son and a nursing assistant called for a nurse. The note included, Resident was noted to be choking. [MEDICATION NAME] maneuver performed, resident was transferred from the wheelchair to the bed, abdominal thrusts performed. Resident then began to make eye contact and started to mumble. O2 (oxygen) @ (at) 10L (ten liters) with non-rebreather applied, 20g (20 gauge) IV (intravenous) inserted to left inner arm infusing NS (normal saline). Resident's family stated that resident had choked on her hot dog stating 'she put the whole thing in her mouth' . She was transferred to the hospital by ambulance at 7:20 p.m. A review of the physician's orders [REDACTED].#142 was to receive a mechanical soft diet with no bread, and her food was to be cut into small pieces. Further review of the resident's medical record found that on 03/02/14, the resident experienced vomiting and had a decreased level of consciousness. She was transferred to the hospital, where, according to the hospital records, she was admitted due to aspiration (entry of foreign material into the airway). During her hospitalization , she received total [MEDICATION NAME] nutrition (TPN - which is nutrition provided intravenously (IV)). She returned to the facility on [DATE] with physician's orders [REDACTED]. Her readmission orders [REDACTED] which were interventions put in place prior to her hospitalization on [DATE]. These restrictions were, however, included on the resident's dietary card that was on the tray with her meals. She was also to receive a speech therapy evaluation. Review of the resident's plan of care in effect prior to the resident's hospitalization on [DATE], and the care plan revised when she returned on 03/24/14, found the plans did not identify any issues with swallowing problems or any special precautions to be taken for this resident. There were no instructions provided for the amount of supervision needed. Prior to her discharge to the hospital on [DATE], the resident had a recommendation from the Speech Therapist for No Bread and for her food to be cut into bite sizes pieces in addition to the mechanical soft diet. It was unclear if this restriction was to be continued when she returned from the hospital because theses interventions were not included in the resident's care plan in effect prior to her admission to the hospital with aspiration. The care plan was not individualized to identify this resident's specific problem, but stated provide diet as ordered. In an interview with the Speech Pathologist (Employee #171), on 04/22/14 at 10:00 a.m., she stated this resident should not have had bread and her food (fruits and vegetables) should have been cut into bite size pieces. She also said the resident should have had ground meats and not a whole hot dog. According to the Speech Pathologist, the resident was on the Red Napkin program because she had decreased intake. The Red Napkin also meant the resident required supervision. Employee #171 said she had seen the resident in the past and recommended no bread and for the resident's food to be cut in small pieces. She commented this was included on the resident's physician's orders [REDACTED]. This was not because the resident did not like bread, but she should not have it due to her swallowing problems. The Speech Pathologist stated this precaution should have been continued when the resident came back from the hospital. Employee #171 said she was treating the resident for swallowing problems, but did not realize the precautions previously put in place were not continued. This information was still written on her tray card that came with her meal each day. She confirmed anytime a resident went to the hospital and had restrictions put in place by the Speech Therapist, the restrictions should continue when the resident returned. During an interview with the dietitian (Employee #229), on 04/22/14 at 10:15 a.m., she indicated speech therapy had made recommendations for Resident #142 to have no bread. She said this recommendation was made due to the resident's unsafe swallowing. No bread was written on the resident's dietary card and listed as a dislike, but was not really a dislike. It was just written as a dislike to remind the kitchen not to give bread to the resident. She said all of the residents in the facility who had a bread restriction due to unsafe swallowing, had bread written in the dislikes so they would not receive it. She said none of these were truly dislikes, it was for swallowing issues. She stated the kitchen knew if the ticket said the resident disliked bread, the resident should not receive it. During an interview with the dietary manager (Employee #228), on 04/22/14 at 10:20 a.m., she said Resident #142 should not have had a hot dog or a bun. She said the diet recorded in the kitchen stated the resident was to have a mechanical soft diet with no bread. She said the no bread restriction was carried over from before she went to the hospital because they carried these restrictions forward, unless they were changed or discontinued. Her diet was still mechanical soft and the meats should be ground mechanically. In an interview with a registered nurse, Employee #22 (Assistant Director of Nursing), 04/22/14 at 9:45 a.m., an inquiry was made about the procedure for the facility after a resident returned from the hospital. She was asked how the facility ensured the restrictions and precautions previously in place were continued upon the resident's return. She said after so many days, the computer discontinued all of these interventions and the resident was addressed as a new admission. She said the nurses had to look at the prior record for things like restrictions, that were previously part of the resident's care, to see whether the restrictions should be continued. She was specifically questioned about Resident #142's swallowing issues regarding the order for no bread and to cut the food into small pieces. She stated those restrictions should have been included when the nurse wrote the orders upon the resident's return from the hospital, or at least discussed with the physician. She verified there was no evidence this was reviewed when the resident returned from the hospital. In a telephone interview with Resident #142's son, on 04/22/14 at 2:00 p.m., he said he and his wife were in the room visiting with his mother when her dinner tray was brought to her on 03/26/14. He stated he was standing at the door and the girl handed him his mother's tray. He verified the nursing assistant did not look at what was on the tray, she just gave it to him with the lid still covering the plate. He stated when they saw the food on the tray, he said to his mother Are you sure you are allowed to have that? He said he was concerned about her having an entire hot dog because the facility had called him the night before and told him Speech Therapy was going to analyze her because she was having swallowing problems. He said he was also concerned because his mother had just been in the hospital with aspiration and had not been eating anything in the hospital. In the hospital, they were feeding her through her veins with an IV. He said his mother picked up the hot dog and the bun and put the whole thing in her mouth. He said her cheeks were pushed way out on both sides. He told her she had way too much in her mouth and tried to get her to spit it out and then she choked and he yelled for help. A telephone interview was conducted with a nursing assistant (Employee #161) 04/22/14 at 7:30 p.m. She confirmed she had been the nursing assistant responsible for Resident #142 on the evening of 03/26/14. She stated she took the tray off the cart and gave it to the resident's son. She verified she did not remove the lid and look at the resident's tray. She could not confirm whether it was the correct diet because she did not see it, she just gave it to the family. On 04/23/14 at 2:00 p.m., in an interview, the Director of Nursing (Employee #73) stated she was present the night of the choking incident involving Resident #142. She said she was still in the facility that evening and heard the page over the loud speaker for a nurse to come immediately to the resident's room. She stated when she arrived, staff were performing the [MEDICATION NAME] maneuver on Resident #142. She said she immediately went to the resident's tray and noted there was one third (1/3) of an entire hot dog on the tray. She stated the resident's tray card was lying on her tray and indicated she was to get a mechanical soft diet with no bread. She immediately identified the resident had been served the incorrect diet of an entire hot dog that was not ground on a bun. She said prior to her leaving that day, she made sure there were no other residents who had received the wrong diet. The director of nursing stated the nursing assistants were supposed to look at the trays when they served them to make sure the residents received the correct diet. The staff were to check the tray with the diet card that was placed on their tray as a way to double check. When Employee #73 was asked whether an issue was identified or any plan of action was implemented to ensure this did not reoccur, she stated she had not implemented a plan to evaluate how this happened and to prevent reoccurrence. The person identified to investigate incidents in the facility to determine if abuse or neglect occurred was a Registered Nurse (Employee #199). She was interviewed on 04/23/14 at 2:30 p.m. regarding this incident. She was asked if the incident was identified as neglect. She stated no it was not. Employee #199 said she did not identify the resident got anything she was not supposed to get that would result in her to choking. When asked if this would have been determined as neglect if she had identified the resident received the incorrect diet, she said yes because that would have been failure to provide a service.",2017-04-01
7520,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-04-24,225,D,1,0,HZEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview, the facility failed to thoroughly investigate and report an incident of neglect. A resident did not receive a diet in the form to meet her needs, a mechanical soft diet, as ordered by the physician. She was served a whole hot dog on a bun. As a result of being served the incorrect diet, the resident choked and was sent to the hospital. The facility's investigation contained inaccurate information in the summary report. The facility failed to identify the type of diet this resident received for that meal which resulted in the choking episode, and failed to interview pertinent staff and family members who were present when the incident occurred. The facility also failed to identify or report this as an incident of neglect because it was based on inaccurate and incomplete information in their investigation. This was identified for one (1) of thirty-eight (38) reportable incidents reviewed for three (3) months. Resident identifier: #142. Facility Census: 141. Findings include: a) Resident #142 Review of the resident's medical record found a nursing entry, dated 03/26/14 at 19:21 (7:21 p.m.), noting the resident's son and a nursing assistant called for a nurse. The note included, Resident was noted to be choking. [MEDICATION NAME] maneuver performed, resident was transferred from the wheelchair to the bed, abdominal thrusts performed. Resident then began to make eye contact and started to mumble. O2 (oxygen) @ (at) 10L (ten liters) with non-rebreather applied, 20g (20 gauge) IV (intravenous) inserted to left inner arm infusing NS (normal saline). Resident's family stated that resident had choked on her hot dog stating 'she put the whole thing in her mouth' . She was transferred to the hospital by ambulance at 7:20 p.m. A review of the facility's investigation files, on 04/21/14 at 2:30 p.m., found this incident was investigated, but was not reported to the State agencies. A Registered Nurse (Employee #199) was identified as the person in charge of conducting the investigations. The investigative report was reviewed. It contained a section titled Summary of Critical Information Obtained During Investigation. In this section it was documented, Resident had a recent diet change on 03/21/14 to mechanical soft CHO (carbohydrate) controlled with thin liquids. Speech therapy had resident on case load for communication enhancement. SLP (speech-language pathologist) noted the resident ability to swallow was notably weaker. Staff reports a poor intake recently and that resident would drink more than she ate. On date of incident, resident was served a mechanical soft meal of hot dog with chili and coleslaw on a bun. She was also served soup with crackers, Family was present in room. Dietician stated that resident should not have been served a bun with her meal due to CHO controlled. Resident was monitored by CNA (certified nursing assistant) with family present as well. Hot dog wiener was moist ground according to statements obtained. Resident diet ticket stated that dislikes was bread. Family stated she put the whole thing in her mouth and resident became choked and intervention was necessary. This incident was investigated by the facility. The conclusion on the summary report was, Resident was served a mechanical soft diet but was given a bun which was listed on her dislikes. The resident was found to have a exacerbation of malignant brain neoplasm at the hospital. SLP (speech and language pathology) stated the resident was having problems with oral prep stage; Resident remained out of facility at end of the investigation. Dietician performed education with dietary department on diets. Staff member interviews and a family interview revealed the facility's investigation did not contain accurate information. All staff members involved in the incident and who were working that shift were not interviewed. The investigation did not include written statements from the Director of Nursing (Employee #73), who observed the resident's diet tray and knew the resident did not receive a mechanical soft diet, or any kitchen worker who assisted with tray preparation. It was identified the dietary employee who assisted with the trays that day was Employee #221. He verified during a telephone interview, on 04/23/14 at 11:30 a.m., no one had asked him to provide a written statement while this was being investigated. There were incorrect statements about speech therapy and the dietary manager included in this investigation. The information utilized to form the conclusion was not what was said in the written statements, or what was reflected in the medical record. The investigation did not include an interview with the family members who were present and witnessed what the resident had been served. There was no evidence in the statements that identified the hot dog was moist ground as stated in the investigative report. The written statement provided by the Speech Pathologist (Employee #171) during the investigation was dated 03/27/14. This statement noted Resident #142's diet order was for mechanical soft with thin liquids. The statement included, Her PO (by mouth) intake has declined recently because she says she is not hungry. Her swallowing ability is notably weaker It strikes me as odd that they would serve her a whole hot dog. I feel the meat should have been ground a least. I did work with her yesterday. I have her for speech to enhance communication which is very limited. She has some trouble with her oral prep stage but is able to clear her oral cavity. She drinks more than she eats. CNAs (certified nursing assistants) have been reporting that she has been eating fine for breakfast if she does eat. To me her cognition is stable and I have not noticed an overall decline but this is hard for me to determine due to her limited communication. This Speech Pathologist (Employee #171) was interviewed on 04/22/14 at 10:00 a.m. She stated this resident should not have had bread and her food should have been cut into bite sizes. She also said the resident should have had ground meats and not a whole hot dog. According to the speech pathologist, the resident was on the Red Napkin program because she had decreased intake. The red napkin also meant the resident required supervision. In the past, Employee #171 said she saw the resident and recommended no bread and for her food to be cut in small pieces, and this was included on her physician orders. It was also written on the resident's dietary card as a dislike to remind the kitchen not to give her bread. This was not because she did not like bread, but because she should not have it due to swallowing problems. She stated this precaution should have been continued when the resident came back from the hospital. Employee #171 said she was treating the resident for swallowing, but did not realize this precaution, previously put in place, was not continued. This information was still written on her tray card which came with her meal each day. She confirmed anytime someone went to the hospital, any restrictions put in place by the speech therapist, should be continued when the resident returned. A copy of the resident's speech therapy evaluation and treatment plan was provided by Employee #171. This evaluation, dated 03/24/14, identified the resident was having difficulty eating. She was evaluated for her swallowing function and demonstrated mild to moderate deficits. The goal established for treatment was, Pt (patient) will safely swallow mechanical soft /thin with no complications of aspiration and to ensure nutrition/hydration adequate. The treatment approaches listed treatment of [REDACTED]. The facility's investigation report, and statements gathered for this incident, included a written statement from the dietitian dated 03/27/14. The statement included, A mechanical soft diet is what the resident was ordered. She should not have gotten a bun last night. She should have gotten ground up wiener and chili over it and coleslaw and soup and crackers. She is red napkin program so she should have had some supervision or check ins. During an interview with the dietitian (Employee # 229), on 04/22/14 at 10:15 a.m., she indicated speech therapy had made recommendations for Resident # 142 to have no bread. She said this recommendation was made due to her unsafe swallowing. This was written on her dietary card and listed as a dislike, but was not really a dislike. It was just written as a dislike to remind the kitchen staff not to give it to her. She stated everyone was aware of this. She confirmed that all of the residents in the facility, who had a bread restriction due to unsafe swallowing, had bread written in the dislikes section so the residents would not receive it. She said none of these were truly dislikes, it was for swallowing issues. She stated the kitchen knew if the ticket had the resident disliked bread, the resident should not get bread. Employee #229 was asked about the statement in the investigation summary that stated she said the resident should not have been served a bun with her meal due to a CHO (carbohydrate) controlled diet. She verified she had not said this, and it was not in her written statement provided to the facility. She said she would not have said this because even if the resident was on a CHO (carbohydrate) controlled diet, the resident could still have bread. She reiterated she had not said this. The statements were reviewed and there was nothing to indicate the diet this resident received the evening of 03/16/14. There was also nothing to confirm she received a mechanical soft diet which was recorded on the investigative summary. In an interview with a registered nurse, Employee #22 (Assistant Director of Nursing), 04/22/14 at 9:45 a.m., she confirmed she was present when the staff were doing the [MEDICATION NAME] maneuver for this resident. She said she did not observe the resident's tray or notice whether she had ground meat. When asked about the investigation, she stated no one had asked her to provide a written statement. A telephone interview was conducted with Resident #142's son on 04/22/14 at 2:00 p.m. He said he and his wife were in the room visiting with his mother when her dinner tray was brought to her on 03/26/14. The son stated he was standing at the door and the girl handed him his mother's tray. He verified the nursing assistant did not open it or look at the food, she just gave the tray to them with the lid still covering the meal. He stated when they saw the food on the tray, he asked his mother, Are you sure you are allowed to have that? He said he was concerned about her having a whole hot dog because the facility had called him the night before and told him Speech Therapy was going to analyze her because she was having swallowing problems. He said he was also concerned because his mother had just been in the hospital with aspiration and had not been eating anything in the hospital. He said they were feeding her through her veins with an IV (intravenously with TPN -total [MEDICATION NAME] nutrition). He said his mother picked up the hot dog and the bun and put the whole thing in her mouth. He said her cheeks were pushed way out on both sides. He told her she had way too much in her mouth and tried to get her to spit it out and then she choked and he yelled for help. He was asked if the facility had talked to him and he stated No. There was no evidence the facility attempted to talk to him to see what kind of meal she had been served. A telephone interview was conducted with a nursing assistant (Employee #161) on 04/22/14 at 7:30 p.m. She confirmed she had been the nursing assistant responsible for Resident #142 on the evening of 03/26/14. She stated she took the tray off the cart and gave it to the son who was visiting his mother. She verified she did not remove the lid and look at the resident's tray. She said she could not confirm if the resident had received the correct diet because she did not see it, she just gave it to the family. The Director of Nursing (Employee 73) was interviewed on 04/23/14 at 2:00 p.m. She stated she was present the night of the choking incident involving Resident #142. She said she was still there that evening and heard the page over the loud speaker for a nurse to come immediately to the resident's room. She stated when she arrived in the resident's room, staff were performing the [MEDICATION NAME] maneuver on Resident #142. She said she immediately went to the resident's tray and found one third (1/3) of a whole hot dog on her tray. She stated the resident's tray card was lying on her tray and indicated she was to get a mechanical soft diet with no bread. She immediately identified the resident was served the incorrect diet, a whole hot dog (not ground) on a bun. She said, prior to leaving that day, she made sure there were no other residents who had received the wrong diet. The director of nursing stated the nursing assistants were supposed to look at the trays when they served them and make sure the residents received the correct diet. The diet cards for the residents were placed on the trays as a way to double check. Employee #73 was asked if a plan of action was implemented to ensure this did not reoccur. She stated she had not implemented a plan to evaluate how this happened and to prevent reoccurrence. The director of nursing verified she did a written statement for Employee #199 when she was investigating this issue. When asked if she did a written statement, she said she had done one. She was given the investigation packet and verified her written statement was not included in the investigation packet. She was asked about the reporting of this issue and she stated We did report it. We self-reported this issue because I remember talking about it and if we should report it as neglect or an unusual incident and we talked about it at our morning meeting. She said the investigation documentation provided was not everything and there must be some more documentation in the office. At 2:30 p.m., on 04/23/14, Employee #73 (the director of nursing) and Employee #199 (resident liaison) were questioned together about this incident. Employee #73 asked where her written statement was, because it was not in the investigative report. Employee #199 told Employee #73 she did not have a written statement from her (#73). Employee #73 told her she gave her (#199) a statement and told her (#199) she saw the hot dog on the resident's tray. Employee #199 insisted Employee #73 did not give her a statement. Employee #199, a Registered Nurse (RN), was identified as the person who investigated incidents in the facility to determine whether abuse or neglect occurred. In an interview on 04/23/14 at 2:30 p.m., she was asked whether this incident was identified as neglect. She stated, No, it was not because she never identified the resident got anything she was not supposed to get that would result in her to choking. Employee #199 confirmed the investigation did not include interviews with everyone who was present during this incident to identify whether the resident had received the correct diet or not. She also confirmed if she had identified the resident received the incorrect diet, the incident would have been determined to be neglect because it would have been failure to provide a service. Employee #199 confirmed the investigation did not contain accurate information, but said she went by what was given to her in writing. She verified she had not interviewed everyone present during this resident's meal that day to see if someone could identify what diet the resident was served. She also verified she had not spoken with the son who was present with his mother when she choked. She again denied speaking with the Director of Nursing, who said she observed the resident received a whole hot dog. She stated she did not know Speech Therapy was treating this resident for swallowing. When Employee #199, was informed the dietitian had denied having said what was attributed to her in the report, and the report did not accurately reflect what the dietitian had written in her statement, she had no comment.",2017-04-01
7521,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-04-24,253,E,1,0,HZEQ11,"Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a clean and orderly environment for four (4) of fifteen (15) resident rooms observed on the A wing. Multiple Styrofoam cups, open cans of Ensure, and other beverages were observed in residents' rooms. Other observations included items stored on the floor, one (1) room had a hole in the ceiling, residents' clothing was not stored neatly, soiled rags and debris were on the floor, trash cans were overflowing, and briefs were not stored properly. The unoccupied bed in one (1) room had various items stored on the bed. This practice had the potential to affect more than an isolated number of residents. Facility Census: 141. Findings include: a) Room ASPC Observation of this room, on 04/22/14 at 2:00 p.m., found a hole in the ceiling, Styrofoam cups with straws on the bedside table the dressers. There was also a laundry hamper overflowing with dirty clothes in the room in plain view. There was an open can of Ensure on the dresser that was not empty. The occupant of this room had been in the hospital for over 24 hours. This room was observed again on 04/22/14 at 4:00 p.m. with a nurse (Employee # 41) present. The hole in the ceiling now had a pan placed under it to catch the plaster falling from the ceiling. The laundry hamper was still overflowing and in plain view as one entered the room. In addition, there were still multiple cups with straws on the dresser, and the can of opened Ensure remained on the dresser. During this observation, Employee #41 confirmed the room was not tidy. b) Room A-2 This room was designated as an isolation room where a resident in isolation resided. During an observation on 04/22/14 at 2:05 p.m., the resident's closet was stuffed with clothes on both sides. Some clothes were hanging, but there were large trash bags full of clothes stuffed in the closet. In addition, there was a box of clothes on the floor, and clothes were thrown over the hanging rod of the closet. There was only one (1) resident residing in the room. The empty bed had supplies piled on it that included packages of briefs, sheets, towels, a bathing pan, multiple clothes, and blankets. There were two (2) empty supplement cans on the dresser and two (2) Styrofoam cups with straws on the night stand. There were dirty rags, which appeared to be washcloth and a pillow on the floor. An opened carton of milk and an opened can of Ensure were on the bedside table. On the floor were yellow ties from the isolation gowns which staff wore while in the room. There was also other debris on the floor. The trash can was overflowing and the walls were soiled with unknown brown and tan substances. This room was again observed on 04/23/14 at 4:00 with Employee # 41. She agreed this room needed attention. She picked up the trash immediately. She said the facility used Styrofoam cups instead of water pitchers. She confirmed the trash can was overflowing and verified the room had debris on the floor and the walls were soiled. c) Room A08 Observation of this room on 04/22/14 at 2:15 p.m., found the clothes in the closet were not hung up, but were thrown on the floor and over the rack in the closet. Wadded clothing was piled from the closet floor to the clothes thrown over the rack in the closet. During another observation, on 04/23/14 at 4:10 p.m., Employee # 41 verified the closet was cluttered and disorderly. d) Room A-09 Observation of this room, on 04/23/14 at 4:15 p.m., found several briefs on the floor in packages, three (3) large Styrofoam cups at the bedside, and three (3) open cartons of drinks on the resident's bedside table. The closet was full of clean briefs stored on the floor and the trash can was overflowing.",2017-04-01
7522,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-04-24,323,G,1,0,HZEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I Based on record review, staff interview, and family interview, the facility failed to ensure the resident environment was as free of accident hazards as possible for one (1) of nine (9) sample residents,and failed to provide adequate supervision during meal times. A resident with a known swallowing problem received the incorrect diet and was not provided with adequate supervision to prevent choking. Resident #142 was on a mechanical soft diet with ground meat, was not to receive bread, and her foods (fruits and vegetables) were to be cut in small pieces. She was served a whole hot dog on a bun resulting in her becoming choked requiring hospitalization . This practice resulted in actual harm for the resident. Resident identifier: #142. Facility Census: 141. Findings include: a) Resident #142 Review of the resident's medical record found a nursing entry, dated 03/26/14 at 19:21 (7:21 p.m.), noting the resident's son and a nursing assistant called for a nurse. The note included, Resident was noted to be choking. Heimlich maneuver performed, resident was transferred from the wheelchair to the bed, abdominal thrusts performed. Resident then began to make eye contact and started to mumble. O2 (oxygen) @ (at) 10L (ten liters) with non-rebreather applied, 20g (20 gauge) IV (intravenous) inserted to left inner arm infusing NS (normal saline). Resident's family stated that resident had choked on her hot dog stating 'she put the whole thing in her mouth' . She was transferred to the hospital by ambulance at 7:20 p.m. A review of the physician orders [REDACTED].#142 was to receive a mechanical soft diet (ground meat) with no bread and her food (such as fruits and vegetables) was to be cut into small pieces. Further review of the medical record revealed the resident was transferred to the hospital on [DATE]. According to her hospital records, she was admitted due to aspiration. During her hospitalization she received TPN (total pretrial nutrition). She returned to the facility on [DATE] with physician's orders [REDACTED]. There were no restrictions in this order indicating she was to have no bread or to cut food up into small pieces, which were interventions in place prior to her hospitalization . These instructions were included on the dietary card which was on the tray when the resident was served her meals. The care plan in effect prior to the resident's hospitalization was reviewed. This care plan did not identify any issues with swallowing problems. The instructions included in her orders were not specified in the care plan for the staff providing care. The care plan did not reflect she was not to have bread or that her food was to be cut in small pieces or that she had any swallowing issues that needed to be monitored. The Speech Pathologist (Employee #171) was interviewed 04/22/14 at 10:00 a.m. She stated this resident should not have had bread and her food should have been cut into bite sized pieces. She also said she should have had ground meats. She said the resident was on the Red Napkin program because she had decreased intake. The red napkin also meant she required supervision. Employee #171 said she had seen the resident in the past and recommended no bread and her food to be cut in small pieces. This was included in her physician orders. The instructions were written on the resident's dietary card as a dislike to remind the kitchen not to give her bread. This was not because she did not like bread, but she should not have it due to swallowing problems. She stated these precautions should have been continued when the resident came back from the hospital. Employee #171 said she was treating the resident for swallowing, but did not realize the precautions previously put in place were not continued. It was still written on the tray card that accompanied the resident's meal each day. She confirmed anytime someone went to the hospital and had restrictions put in place by Speech Therapy, those should be continued when the resident returned. Speech therapy would evaluate the resident when he/she returned and if there were changes, new recommendations would be written. During an interview with the dietitian (Employee #229) on 04/22/14 at 10:15 a.m., she said speech therapy had made a recommendation for Resident #142 to have no bread due to the resident's unsafe swallowing. This instruction was written on the resident's dietary card and listed as a dislike, but was not really a dislike. It was just written as a dislike to remind the kitchen not to give it to her. She confirmed that all of the residents in the facility, who had a bread restriction due to unsafe swallowing, had bread written in the dislikes so they would not receive it. She said none of these were truly dislikes, it was for swallowing issues. She stated the kitchen staff knew if the ticket had the resident disliked bread, the resident should not be given bread. In an interview with the dietary manager (Employee #228) on 04/22/14 at 10:20 a.m., she said Resident #142 should not have had a whole hot dog or a bun. She said the diet recorded in the kitchen stated the resident was to have a mechanical soft diet (ground meat) with no bread. She said the no bread restriction was carried over from before she went to the hospital because they carry these restrictions forward unless they are changed or discontinued. On 04/22/14 at 9:45 a.m., a registered nurse, Employee #22 (Assistant Director of Nursing), was asked how the the facility ensured restrictions and precautions, that had been in place prior to a resident's hospitalization , were continued when the resident returned. She said after so many days the computer discontinued these interventions and the resident was addressed as a new admission. She said the nurses have to look at the prior record for things like restrictions, that were previously part of their care, to see if those should be continued. She was specifically questioned about Resident #142's swallowing issues and the order for no bread and cut the food into small pieces. She stated those restrictions should have been included when the nurse wrote the orders upon the resident's return from the hospital, or at least discussed with the physician. She verified there was no evidence this was reviewed when the resident returned from the hospital. A telephone interview was conducted with Resident #142's son on 04/22/14 at 2:00 p.m. He said he and his wife were in the room visiting with his mother when her dinner tray was brought to her on 03/26/14. The son stated he was standing at the door and the girl handed him his mother's tray. He verified the nursing assistant did not open it or look at it, she just gave it to them with the lid still covering the food. He stated when they saw the food on the tray he said to his mother, Are you sure you are allowed to have that? He said he was concerned about her having a whole hot dog because the facility had called him the night before and told him Speech Therapy was going to evaluate her because she was having swallowing problems. He said he was also concerned because his mother had just been in the hospital with aspiration and had not been eating anything in the hospital. The hospital had fed her through her veins with an IV (intravenously with TPN - total parenteral nutrition). He said his mother picked up the hot dog and the bun and put the whole thing in her mouth. He said her cheeks were pushed way out on both sides. He told her she had way too much in her mouth and he tried to get her to spit it out. She choked and he yelled for help. A telephone interview was conducted with a nursing assistant (Employee #161) 04/22/14 at 7:30 p.m. She confirmed she had been the nursing assistant responsible for Resident #142 on the evening of 03/26/14. She stated she took the tray off the cart and gave it to the son who was visiting his mother. She verified she did not remove the lid and look at the resident's tray. She could not confirm whether the resident received the correct diet, because she did not see it, she just gave the tray to the family. The Director of Nursing was interviewed on 04/23/14 at 2:00 p.m. She stated she was present the night of the choking incident involving Resident #142. She said she was still in the facility that evening and heard the page over the loud speaker for a nurse to come immediately to the resident's room. She stated when she went to the room, staff were performing the Heimlich maneuver on Resident #142. She said she immediately went to the resident's tray and found one-third (1/3) of a whole hot dog on the tray. She stated the resident's tray card was laying on her tray. It indicated the resident was to receive a mechanical soft diet with no bread. She immediately identified the resident was served the incorrect diet. She had a whole hot dog, that was not ground, and it was on a bun. She said, prior to leaving the facility, she made sure there were no other residents who had received the wrong diet. The director of nursing stated the nursing assistants were supposed to look at the trays as they were served to make sure the resident received the correct diet. The residents' diet cards were placed on their trays as a way to double check. Part II Based on observation and staff interview, the facility failed to ensure the environment was as safe and free of accident hazards as possible Potentially hazardous items were in residents' rooms on the A unit. This had the potential to affect more than an isolated number of residents. Facility census: 141. Findings include: a) Room 210 During an observation on 04/22/14 at 11:55 a.m., a container of Clorox disinfecting wipes were observed on the floor just inside the door of Room 210. Review of the label on the Clorox disinfecting wipes found the wipes were for cleaning surfaces. The precautionary statements included, Hazardous to Humans. A warning on the label also stated Not for cleaning or sanitizing skin. Do not use as diaper wipe or personal cleansing. There was also a warning that stated Keep out of reach of Children. On 04/22/14 at 12:00 p.m., Employee #36, a nurse aide, confirmed these wipes were in the room and should not be. They were immediately removed from the room. b) Room A-SPC During a tour of the environment on the A unit, on 04/22/14 at 4:00 p.m., there were potentially harmful items on a bedside table in Room A-SPC. These items included eye drops (artificial tears), Max Vision vitamins, Dyna-Hex surgical cleanse, Aspercreme, and a disinfectant spray with a label that stated Keep out of reach of Children. The nurse (Employee #41), who was present at the time of these observations, immediately removed the items. She confirmed these items were not to be in the room and accessible to residents. She also verified there was only one (1) resident occupying the room, and she was in the hospital at that time.",2017-04-01
7523,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-04-24,365,G,1,0,HZEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview, the facility failed to ensure one (1) of nine (9) sampled residents was provided food in a form to meet her individual needs. The resident had a physician's orders [REDACTED]. This diet called for ground meat. The resident received a whole hot dog instead of ground meat. The resident choked on the hot dog, requiring a transfer to the hospital. Resident identifier: #142. Facility census: 141. Findings include: a) Resident # 142 A nursing note dated 03/26/14 indicated this resident's son and a nursing assistant called for a nurse. The note stated The resident was noted to be choking. [MEDICATION NAME] maneuver performed, resident was transferred from the wheelchair to the bed, abdominal thrusts performed. Resident then began to make eye contact and started to mumble. The resident's family stated that the resident had choked on her hot dog stating she put the whole thing in her mouth. The resident was transferred to the hospital at 7:20 p.m. on 03/26/14. Resident # 142's physician's orders [REDACTED]. This diet called for ground meat. The Director of Nursing was interviewed on 04/23/14 at 2:00 p.m. She stated she was present the night of the choking incident involving Resident #142. She said she was still there that evening and heard the page over the loud speaker for a nurse to come immediately to this resident's room. She stated when she got to the room, staff was performing the [MEDICATION NAME] maneuver on Resident #142. She said she immediately went to her tray and observed one third (1/3) of a whole hot dog on her tray. She stated the resident's tray card was on her tray and indicated she was to get a mechanical soft diet with no bread. She said she immediately identified the resident was served the incorrect diet. She was served a whole hot dog (not ground meat) on a bun. A phone interview was conducted with Resident # 142's son on 04/22/14 at 2:00 p.m He said he and his wife were in the room visiting with his mother when her dinner tray was brought to her on 03/26/14. The son stated he was standing at the door and the girl handed him his mothers' tray. He verified the nursing assistant did not open it or look at it, she just gave it to him with the lid still covering it. He stated when they saw the food on the tray he said to his mother Are you sure you are allowed to have that? He said he was concerned she had a whole hot dog because the facility had called him the night before and told him Speech Therapy was going to evaluate her because due to swallowing problems. He said he was also concerned because his mother had just been in the hospital with aspiration and had not been eating anything in the hospital. He said they were feeding her through her veins with and IV (intravenously with TPN -total [MEDICATION NAME] nutrition). He said his mother picked up the hot dog and the bun and put the whole thing in her mouth. He said her cheeks were pushed way out on both sides. He told her she had way too much in her mouth, and tried to get her to spit it out. She choked and he yelled for help. The resident was transferred to the hospital.",2017-04-01
7802,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,281,H,0,1,0MB311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review and resident interview, the facility failed to assess and treat Resident #170's pain in accordance with professional standards which has been a primary factor in her refusing to go to [MEDICAL TREATMENT]. Her refusals of [MEDICAL TREATMENT] has the potential to cause serious harm and/or death. The resident has already suffered actual harm by the facility's failure to treat her pain on multiple occasions. The resident since [DATE] has refused to go to six (6) out of eight (8) [MEDICAL TREATMENT] treatments ([DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]). Resident #170 only recieved one full treatment since the placement of the wound vac on [DATE]. She did go to [MEDICAL TREATMENT] on [DATE], but her treatment had to be stopped after seventy-nine (79) minutes because of the residents complaints of pain. The clinical diretor of the local dialyis center during and interview on [DATE] at 1:35 p.m. stated the resident was complaining of pain related to her wound vac on [DATE] and that is why her treatment had to be stopped. Review of Resident #170's medical records, staff interviews and resident interviews found on multiple occasions from [DATE] through [DATE] the resident had refused [MEDICAL TREATMENT] treatments. An interview with Resident #170 revealed she was not going to [MEDICAL TREATMENT] because of pain caused from the [DEVICE] which was placed on [DATE]. The record contained no information to indicate Resident #170's attending physician and/or nurse practitioner was notified of her refusals of [MEDICAL TREATMENT] and/or pain. The [MEDICAL TREATMENT] center on two (2) occasions [DATE] and [DATE] sent recommendations to discontinue Resident #170's [MEDICATION NAME] the facility did not address this. In fact she continued to receive this medication and the physician had not been notified of the recommendations as of [DATE]. The failures to assess and treat the residents pain which has caused her to refuse [MEDICAL TREATMENT] has resulted in Resident #170 being at immediate risk for serious harm and/or death. This has resulted in the determination of an immediate jeopardy. The nursing home administrator (NHA) and the Director of Nursing (DON) were notified of the immediate jeopardy at 1:45 p.m. on [DATE]. The facility provided a plan of correction to the State agency at 5:33 p.m. on [DATE], which the State agency reviewed and accepted at 5:35 p.m. on [DATE]. The State agency then observed for implementation of the plan of correction and abated the immediacy at 11:05 p.m. on [DATE]. This immediate jeopardy began on [DATE], when the facility first failed to provide appropriate assessment of pain and pain management techniques by not notifying Resident #170's attending physician and/or nurse practitioner when she refused to go to [MEDICAL TREATMENT] treatments due to the pain caused by the [DEVICE]. After the immediacy was removed, a deficient practice remained for the following and the scope and severity was decreased to an K . Additionally, for Resident #170, the facility failed to correlate care between the facility and the [MEDICAL TREATMENT] center and failed to administer the Renavela as directed by the nephrologist. For Resident #225, the facility failed to provide effective pain management by failing to assess his level of pain prior to and timely reassess after the administration of an as needed (PRN) pain medication. These issues were found for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT] and for one (1) of five (5) reviewed for the care area of unnecessary medications. Resident identifier: #170 and #225. Facility census: 178. Findings include: a) Resident #170 A review of Resident #170's medical record at 10:00 a.m. on [DATE] found the resident was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The medical record, reviewed on [DATE] at 3:00 p.m., found an admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], identified the resident scored 15 of a possible 15 for the Brief Interview for Mental Status (BIMS) - indicating the resident was cognitively intact. Review of the nurses' progress notes found Resident #170 was admitted to the facility on [DATE] at 5:35 p.m. Further review of the nursing progress notes found a note written by Employee #282, LPN, on [DATE] at 4:55 p.m. which read, Worsening [MEDICAL CONDITION] to bilateral lower extremities and resident missed [MEDICAL TREATMENT] yesterday. The resident has orders for the following advance directives: CPR (cardiopulmonary resuscitation). Resident admitted to this facility on [DATE]. Skin warm and dry. Respirations even and non-labored. Denies cough or shortness of breath. Resident is becoming short of breath when lying flat or turning in bed. Oxygen saturation is 96% (percent) on room air. Observed 3+ (plus) [MEDICAL CONDITION] to bilateral lower extremities. Notified the NP earlier today with no new orders received. As day has progressed, [MEDICAL CONDITION] has worsened and is now non-pitting. Resident states she was due [MEDICAL TREATMENT] yesterday and was not sent. A progress note written on [DATE] at 11:21 p.m. by Employee #199, registered nurse (RN) read, Per (Name of Hospital) was admitted to hospital for [MEDICAL TREATMENT], [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #170 was re-admitted to the facility on [DATE] after receiving treatment for [REDACTED].#273). Physician orders [REDACTED].#273) read: --Wound care per previous orders. --Daily weight, report increase in [MEDICAL CONDITION] or shortness of breath to physician (#273) --Follow-up at facility by attending physician (#273) --[MEDICAL TREATMENT] as previous (Tuesday, Thursday and Saturday) --Transferring physician (#273) and admit to facility under my service. --admitting [DIAGNOSES REDACTED]. --Code status: Full Code --[MEDICATION NAME] coated Aspirin 81 mg by mouth daily. --[MEDICATION NAME] 50mg by mouth at bedtime --[MEDICATION NAME] 50 mcg topically every three (3) days. --[MEDICATION NAME] 17 grams by mouth every day. --[MEDICATION NAME] 12.5 mg by mouth twice daily, (Hold if systolic blood pressure is 100 or below). --[MEDICATION NAME] 10mg by mouth daily --[MEDICATION NAME] 40 mg by mouth daily --[MEDICATION NAME] 7.5 mg by mouth at bedtime --[MEDICATION NAME] 3,200 mg by mouth three times daily with meals. --[MEDICATION NAME] 200mg by mouth three times daily --[MEDICATION NAME] 50 mcg by mouth daily --Dosage of [MEDICATION NAME] will be advised after looking at the [MEDICATION NAME] time/international ratio (PT/INR) tomorrow ([DATE]) --[MEDICATION NAME] 0.25 mg by mouth daily -- Fluid restrictions --[MEDICATION NAME] 325 mg by mouth three times daily --[MEDICATION NAME] ,[DATE] mg by mouth every 6 hours prn Review of the readmission orders [REDACTED]. No orders for fluid restrictions could be found. Additionally, a review of the MAR for ,[DATE] and ,[DATE] found the medication [MEDICATION NAME] was administered at 6:00 a.m., 2:00 p.m. and 10:00 p.m. This medication should have been, administered at meal times which would have been 7:30 a.m., 12:00 p.m. and 5:30 p.m. Review of the Physician Desk Reference (PDR) read, [MEDICATION NAME](R) (sevelamer [MEDICATION NAME]) is indicated for the control of serum phosphorus in patients with [MEDICAL CONDITION] (CKD) on [MEDICAL TREATMENT]. [MEDICATION NAME] (sevelamer) is a [MEDICATION NAME] binder. Sevelamer helps prevent [DIAGNOSES REDACTED] (low levels of calcium in the body) caused by elevated phosphorus. This medication should be taken with meals. During an interview on [DATE] at approximately 3:15 p.m. with local [MEDICAL TREATMENT] center's medical director (nephrologist) it was confirmed the [MEDICATION NAME] should be given with meals otherwise the medication is useless. Further review of the record found a, new patient history and physical completed on [DATE] by Physician #272 read, Patient Was admitted from (Name of hospital #1) with a [DIAGNOSES REDACTED]. Patient was admitted to my services but resident requests to be changed to (Name of physician #273) as he is her regular doctor. Continue current pain regimen. Staff to monitor for pain per facility policy. [MEDICATION NAME] ,[DATE]mg by mouth every six (6) hours prn for pain. Consultation report written on [DATE] by Physician #275, vascular and wound care specialist read, Non-ambulatory. Sacral ulcer- 4 centimeters (cm) in length and 3 cm in width. Stage III- IV. The right heel is fully healed. + Coagulant ([MEDICATION NAME]). Plan- Needs to change dressing to a [DEVICE] to the sacral ulcer. Review of the Treatment Administration Record (TAR) for the month ,[DATE] found the following, Cleanse Stage IV pressure ulcer to sacrum with IHWC (In House Wound Cleanser), pat dry, apply wound vac (vacuum) @ (at) 125 mm(millimeters)/hg (of mercury) every 3 (three) days and prn (as needed) . This had a start date of [DATE]. Review of Resident #170's [MEDICAL TREATMENT] record from [DATE] to [DATE] found the following: --From [DATE] to [DATE]- Resident #170 was ordered a 240 minute [MEDICAL TREATMENT] treatment three times a week. The following occasions are the actual days and times Resident #170 received [MEDICAL TREATMENT]. --[DATE]- 190 minutes of treatment. --[DATE]- 208 minutes of treatment --[DATE]-239 minutes of treatment --[DATE]- 236 minutes of treatment --[DATE] through [DATE]- Resident hospitalized --[DATE]- 206 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]-219 minutes of treatment --[DATE]- 244 minutes of treatment --[DATE]- 196 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]-0 minutes of treatment --[DATE]-237 minutes of treatment --[DATE]- 233 minutes of treatment --[DATE]- 137 minutes of treatment --[DATE]- 200 minutes of treatment --[DATE]- 89 minutes of treatment --[DATE]- 242 minutes of treatment --[DATE] through [DATE]- Resident was hospitalized --[DATE]- 149 minutes of treatment --[DATE]- 253 minutes of treatment --[DATE]- 241 minutes of treatment --[DATE]- 145 minutes of treatment --[DATE]- 173 minutes of treatment --[DATE]- 255 minutes of treatment --[DATE]- 175 minutes of treatment --[DATE]- 93 minutes of treatment --[DATE]- 236 minutes of treatment --[DATE]- 212 minutes of treatment --[DATE]- 179 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 237 minutes of treatment --From [DATE] through [DATE] Resident #170 was ordered a 210 minute [MEDICAL TREATMENT] treatment three times a week. The following are the actual dates and times she received [MEDICAL TREATMENT]. --[DATE]- 215 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE] through [DATE]- Resident hospitalized . -- [DATE] 0 minutes of treatment ( A nurses noted dated [DATE] that the resident stated to the nurse, she was due [MEDICAL TREATMENT] yesterday and was not sent. Resident #170 later that day was sent to the hospital and was admitted for [MEDICAL TREATMENT], [MEDICAL CONDITION], and [MEDICAL CONDITION]) --[DATE] through [DATE]- Resident hospitalized --[DATE]- 217 minutes of treatment --[DATE]- 214 minutes of treatment --[DATE]- 210 minutes of treatment --[DATE]- 211 minutes of treatment --[DATE]-100 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 210 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 79 minutes of treatment -- [DATE] - 0 minutes of treatment. --[DATE]- 0 minutes of treatment In summary from [DATE] through [DATE] resident had the opportunity to go to the [MEDICAL TREATMENT] center for her [MEDICAL TREATMENT] treatment 39 times this is not counting the times the resident was in the hospital because on those dates she was receiving [MEDICAL TREATMENT] at the hospital and could not go in center to get [MEDICAL TREATMENT] even if she wanted to. Of those 39 opportunities resident #170 missed only 7 treatments in their entirety. Of note, one of those treatments was on [DATE] which the resident stated she was not sent by the facility too the [MEDICAL TREATMENT] treatment. She did not refuse this treatment. Upon placement of the resident wound vac on [DATE] through present Resident #170 had the opportunity to go in center for a [MEDICAL TREATMENT] treatment a total of eight (8) times. Of those eight (8) opportunities the resident missed six (6) of those treatments in their entirety. During an Interview with the Chief Medical Officer (CMO) #271 at 10:20 a.m. on [DATE], he stated that Resident #170 had a long history of refusing [MEDICAL TREATMENT]. Also, during an interview with the Medical Director #272 at 12:13 p.m. on [DATE] it was also mentioned Resident #170 had a long history of refusing [MEDICAL TREATMENT]. These statements were not supported by the local [MEDICAL TREATMENT] centers records which showed Resident #170 only missed six (6) out of 38 possible treatments from [DATE] through [DATE]. However, after the wound vac placement she missed six (6) of the eight (8) possible treatments from [DATE] through [DATE] because of what she stated to be pain caused by the wound vac. Review of Resident #170's [MEDICAL TREATMENT] records from [DATE] thru [DATE], Missed HD treatment report and staff interviews, found that beginning on [DATE] through [DATE] Resident #170 either missed or had her [MEDICAL TREATMENT] treatments cut short for the following reasons: --On [DATE], a nursing progress note indicated, Resident refused [MEDICAL TREATMENT]. States she does not feel good. --[DATE], a nursing progress note indicated, Patient went to [MEDICAL TREATMENT] today. Explained the importance of her completing her [MEDICAL TREATMENT] treatment completely for her heath. Patient agreed to go and would try to complete treatment today. --[DATE], nursing progress note indicated, Resident c/o (complains of) wound vac hurting her. Wing nurse notified and resident stated she was medicated. (Name of MD #275) notified and decreased intensity to 50 mmHg per order for two hours and resident continued to c/o the wound vac bothering her and request it be taken off. (Name of MD #275) notified and gave order to hold vac and gave dressing orders until Sunday if he comes and if not, he will evaluate when next in facility. Resident aware. No [MEDICAL TREATMENT] scheduled on this date but information pertinent due to the resident complaining of pain related to her wound vac. --[DATE], nursing progress note indicated, Resident refused to go to [MEDICAL TREATMENT]. States her back is hurting. --[DATE], nursing progress note indicated, Resident agreed to resume wound vac to sacrum. Applied wound vac with no s/s (signs or symptoms) of pain or complications will continue to monitor. -- [DATE], nursing progress note indicated, . Goes to [MEDICAL TREATMENT] Tues., Thurs., and Sat; however resident refused this morning d/t wound vac for sacral ulcer. Often refuses to go to [MEDICAL TREATMENT] . -- [DATE], nursing progress note indicated, Patient refused to go to [MEDICAL TREATMENT] after 3 attempts by the nurse to get her to go. Attempted to explain the importance of completing her [MEDICAL TREATMENT] treatment but she continuously refuses. --No nursing notes for [DATE]. However the [MEDICAL TREATMENT] Communication record indicated the resident was experiencing pain and was crying until her treatment was stopped per her request. She only completed 79 minutes of her 240 minute treatment. --No nursing progress notes for [DATE] pertaining to Resident #170's [MEDICAL TREATMENT] treatment, however the Missed HD Treatment Report indicated the resident did not go to [MEDICAL TREATMENT] on this date. --No nursing progress notes for [DATE] however the Missed HD Treatment Report indicated the resident did not go to [MEDICAL TREATMENT] on this date. In an interview with Resident #170 on [DATE] at 9:35 a.m., the resident stated she did not go to [MEDICAL TREATMENT] today due to her wound vac hurting. She further explained she has chronic pain, but since the wound vac was placed she has experienced more pain and discomfort. She further indicated that since the placement of the wound vac she has had to miss several of her [MEDICAL TREATMENT] treatments due to pain. Resident #170 missed a total of six (6) of her last eight (8) [MEDICAL TREATMENT] treatments since the placement of the wound vac on [DATE]. Of the two (2) treatment she did attend she only completed one full treatment. On [DATE] the residents [MEDICAL TREATMENT] treatment was cut 131 minutes short. There is no evidence in Resident #170's medical record that her attending physician was notified of her missed [MEDICAL TREATMENT] treatments and/or her increased pain associated with the use of her wound vac. A review of Resident #170's controlled medication sheets for her ordered as needed [MEDICATION NAME] found the following, -- [DATE] the resident refused to go to [MEDICAL TREATMENT] due to pain. She was scheduled to leave for [MEDICAL TREATMENT] at 5:30 a.m. however she only received two (2) doses of [MEDICATION NAME] on this date one (1) at 12:00 p.m. and one (1) at 9:00 p.m. -- [DATE] Resident #170 refused to go to [MEDICAL TREATMENT] which she was scheduled to be picked up for at 5:30 a.m. because of back pain. She did not receive her as needed pain medication until 6:00 a.m. she also received additional doses at 1:30 p.m. and 9:00 p.m. -- [DATE] Resident #170 refused to go to [MEDICAL TREATMENT] due to pain from her wound vac. The resident ' s pick up time was scheduled for [MEDICAL TREATMENT] pick up at 5:30 a.m. She did not receive her as needed pain medication until 6:00 a.m., 12:00 p.m., and 9:00 p.m. -- [DATE] the patient had refused to go to [MEDICAL TREATMENT] after three attempts she did not receive pain medication until 10:30 a.m. and 5:30 p.m. Please note the nursing note did not mention why the resident refused [MEDICAL TREATMENT] however, interviews with the resident confirmed she had been refusing [MEDICAL TREATMENT] due to pain from the wound vac. --[DATE] Resident #170 returned from [MEDICAL TREATMENT] after only receiving a 79 minutes treatment when she was scheduled to receive a 240 minute treatment. The [MEDICAL TREATMENT] center wrote on the communication form that Resident #170 ' s treatment had to be stopped because she was crying in pain. She arrived back to the facility at approximately 9:00 a.m. and she received pain medication at 4:30 a.m. and 5:30 p.m. -- [DATE] Resident #170 refused to go to [MEDICAL TREATMENT] she did not receive pain medication until 9:00 a.m. and 9:00 p.m. even though her scheduled pick up time for [MEDICAL TREATMENT] was 5:30 a.m. -- [DATE] Resident #170 again refused to go to [MEDICAL TREATMENT] she had receive pain medication at 4:40 a.m. on this date. -- [DATE], [DATE] and [DATE] the location of the residents and/or complaints of pain were not noted in the medical record. She did however, refuse [MEDICAL TREATMENT] on these dates. An interview with Resident #170 on [DATE] at 9:35 a.m. revealed she had been refusing to go to [MEDICAL TREATMENT] because of pain associated with her wound vac. She indicated she had told the staff about it and this was the reason she could not do her [MEDICAL TREATMENT]. The resident was also interviewed prior to this conversation by a different surveyor on [DATE] at 1:10 p.m. During this interview Resident #170 also stated that she had not been going to [MEDICAL TREATMENT] because of the pain she was experiencing from her wound vac. On [DATE] Resident #170's [MEDICAL TREATMENT] treatment ended after 79 minutes due to complaints of pain as noted by the [MEDICAL TREATMENT] clinic. At 1:35 p.m. on [DATE] the clinical director of the local [MEDICAL TREATMENT] center was interviewed. She was asked if the facility needed to set up a new chair time (scheduled time for [MEDICAL TREATMENT] at the [MEDICAL TREATMENT] center) when Resident #170 was admitted to thier facility she replied, No we do not give up thier chair time when they are in the hospital. She stated, she would have had the same cahir time and no arrangements were needed. When asked why Resident #170's treatment was cut short on [DATE] she stated, Because of pain related to her wound vac. She indicated Resident #170 had at times refused [MEDICAL TREATMENT] prior to the placement of the wound vac, but since its placement these have increased drastically. Further review of the Resident #170's controlled substance utilization record found the following dates and times when Resident #170 was administered her prescribed as needed pain medication with no assessment of where the pain was located, the intensity of the pain prior to administration, and no follow up assessment to determine if the pain medication was effective in relieving the resident pain: --[DATE] at 10:00 a.m. and 6:00 p.m. --[DATE] at 12:00 a.m., 1:00 a.m., and 9:10 p.m. --[DATE] at 4:30 a.m. and 9:00 p.m. --[DATE] at 10:00 p.m. --[DATE] at 9:00 a.m. and 9:00 p.m. --[DATE] at 9:00 a.m. (Not noted on MAR) and 9:00 p.m. --[DATE] at 5:00 a.m. (Marked not given, Wasted on Narcotic sheet), 12:00 p.m. and 9:15 p.m. (Not recorded on MAR). --[DATE] at 7:00 a.m. and 6:00 p.m. --[DATE] at 12:00 a.m. (Not recorded on MAR, 2:00 p.m. (Not recorded on MAR, and 10:00 p.m. (Not recorded on MAR). --[DATE] at 6:20 a.m. and 10:00 p.m. --[DATE] at 12:00 p.m. and 9:30 p.m. --[DATE] at 1:25 p.m. (Not recorded on MAR) and 8:00 p.m. --[DATE] at 5:30 a.m., 11:30 a.m. (Not recorded on MAR) and 6:00 p.m.( Not recorded on MAR) --[DATE] at 12:00 p.m., and 9:00 p.m. (Not recorded on MAR) --[DATE] at 9:00 a.m., 4:30 p.m. and 11:00 p.m. (Not recorded on MAR) --[DATE] at 9:00 p.m. --[DATE] at 11:00 a.m. and 5:00 p.m. --[DATE] at 6:00 a.m., 1:30 p.m., and 9:00 p.m. --[DATE] at 6:30 a.m., 2:30 p.m. (Not recorded on MAR) and 10:30 p.m. --[DATE] at 9:30 a.m. (Not recorded on MAR) and 9:00 p.m. --[DATE] at 6:00 a.m. (Not recorded on MAR). 12:00 p.m. and 9:00 p.m. --[DATE] at 5:00 a.m. (Not recorded on MAR), and 10:30 p.m.( Not recorded on MAR) --[DATE] at 10:30 a.m. and 5:30 p.m. --[DATE] at 5:30 a.m., 5:00 p.m. (Not recorded on MAR)., and 11:00 p.m.( Not recorded on MAR) --[DATE] at 4:30 a.m., and 5:30 p.m. ( Not recorded on MAR) --[DATE] at 5:00 a.m., 2:00 p.m., and 9:00 p.m. --[DATE] at 9:00 a.m., 2:25 p.m. and 9:00 p.m. --[DATE] at 9:00 a.m. (Not recorded on MAR), and 9:00 p.m. (Not recorded on MAR) --[DATE] at 9:00 a.m., 3:00 p.m. and 10:30 p.m. (Not recorded on MAR) --[DATE] at 4:40 a.m. Review of the facility's pain management policy on [DATE] at 9:15 p.m. read: Pain documentation- All residents will be asked/observed for the presence of pain a minimum of daily. This is documented on the Medication Administration Record (MAR) and/or Point of Care (POC). Use of medications will be documented on the resident MAR/POC. Documentation will include: Date/time of resident's pain. Pain rating prior to intervention(s) utilizing the appropriate pain scale. Non-pharmlogical interventions utilized, as indicated. Pain rating after intervention utilizing the appropriate pain scale. Monitoring for side effects. Nurse signature/initials Any resident with persistent pain control issues will have their medical record presented to the physician for review for additional recommendations. In an interview on [DATE] at approximately 10:05 a.m., with the Director of Nursing (DON) she was infomed of Resident #170's multiple documented occasions from [DATE] through [DATE], the resident refused [MEDICAL TREATMENT] treatments, and the resident interview in which she stated she was refusing [MEDICAL TREATMENT] due to caused by the wound vac. The lack of notification of the attending physician and/or nurse practitioner was also brought to her attention at this time. Additionally, the DON was informed the [MEDICAL TREATMENT] center on two (2) occasions [DATE] and [DATE] sent recommendations to discontinue Resident #170's [MEDICATION NAME] which had not yet been addressed by the facility. In fact she continued to receive this medication and the physician had not been notified of the recommendations as of [DATE]. No further information provided prior to the determination of an IJ. Review of Resident #170's [MEDICAL TREATMENT] Communication Records found a recommendation from the [MEDICAL TREATMENT] center on [DATE] which read, Discontinue [MEDICATION NAME] per (Name of local [MEDICAL TREATMENT] clinic's medical director). Again on [DATE] the [MEDICAL TREATMENT] clinical sent another recommendation which read, Discontinue [MEDICATION NAME] per (name of local [MEDICAL TREATMENT] clinic's medical director). Review of Resident #170's MAR's for the months of ,[DATE] and ,[DATE] found the resident has received [MEDICATION NAME] daily since [DATE]. The record contained no evidence this recommendation from the [MEDICAL TREATMENT] clinic had been communicated to the attending physician. There was no evidence to suggest this recommendation had been acted upon. Corporate Nurse Registered Nurse (CNRN) #277 provided a computer print-out of what she stated was pre and post administration pain assessments for Resident #170's as needed pain medication at approximately 2:05 p.m. on [DATE]. Upon review of the computer print-out it was noted the times on the computer print-out did not correlate with the actual times the medication was administered. She was asked why the times did not match and she stated, she would have to get back with the surveyor as to why the times did not match. At the time exit on [DATE] she had provided no additional information or explanation. A Review of the Local [MEDICAL TREATMENT] Clinic's plan and goals for Resident #170's which was located in Resident #170's HD book/chart found the following: --Plan for the month of [DATE] (Printed on [DATE]) Continue high protein diet with supplements. --[MEDICATION NAME]- Protein in the blood helps to fight infections and aid in healing; Goal 3.0. --Potassium (K+) - This mineral is needed for normal heart and muscle action. Too much can make your heart stop. Goal 5.0 --Hemoglobin (HGB) - Contains iron and carries oxygen from the lungs to the body. Goal 10.0. --Phosphorus- The right amount helps keep my bones strong and the heart healthy. Goal 3.4 --Calcium, Total- A mineral needed for healthy bones and muscles. Goal 8.3. --Intact [MEDICAL CONDITION] hormone (iPTH) - Balances calcium and phosphorus in the blood. High phosphorus can cause high iPTH and lead to bone and heart damage. Review of local [MEDICAL TREATMENT] clinic's laboratory results for Resident #170 completed on [DATE], for a Complete Metabolic Panel (CMP), Complete Blood Count) and [MEDICAL CONDITION] Function Panel (TFP) results send on [DATE] at 2:48 p.m. and copy was provided to the NHA so Resident #170's attending physician could review the lab results. The following results were abnormal: --Hemoglobin- 9.0- Low (Normal- ,[DATE]) --Ferritin- 1076 - High-(Normal- 10- 291) --Iron - 25 Low-(Normal- ,[DATE]) --BUN- 161- High-before [MEDICAL TREATMENT] and 46 High after [MEDICAL TREATMENT] (Normal- ,[DATE]) --Creatinine- 4.7 High- (Normal- 0.6- 1.3) --Potassium - 6.0 High-(Normal 3XXX,[DATE].1) --[MEDICATION NAME]- 14 Low - (Normal ,[DATE]) --[MEDICATION NAME]- 3.0 Low-(Normal 3XXX,[DATE].2) --Phosphorus 8.8 High (Normal 2.6- 4.5) --PTH-intact Plasma - After notification of the immediate jeopardy on [DATE], the facility obtained a CMP, CBC, [MEDICAL CONDITION] stimulating hormone (TSH) and a urinalysis and culture and sensitivity of urine. --Hemoglobin- 7.7- Low (Normal- ,[DATE]) --BUN- 135- High- (Normal- ,[DATE]) --Creatinine- 4.0 High- (Normal- 0.6- 1.3) --Potassium - 6.0 High-(Normal 3XXX,[DATE].1) --[MEDICATION NAME]- 2.1- Low-(Normal 3XXX,[DATE].2) --TSH- 7.40 High- (Normal 0.358- 3.74) b) Facility ' s Immediate Plan of Correction --Resident #107 was immediately assessed by the Nurse Practitioner for any health concerns related to pain and refusal of [MEDICAL TREATMENT]. -- Stat labs were ordered, CMP, CBC, TSH, and UA/CS and will be compared with most recent lab from [MEDICAL TREATMENT] upon receipt. --Resident was immediately weighed with a result of 157.5# at 14:22. Resident weighed 162.5 on [DATE]. This is a 5# loss. --Dr. Raheem, attending physician was notified on, [DATE] at 11:15am, regarding resident pain and refusing to attend [MEDICAL TREATMENT] after a discussion with State surveyor. -- All findings will be reviewed with the attending physician for further instruction/orders. --The facility will immediate re-assess all residents that participate in [MEDICAL TREATMENT] for unresolved pain that interferes with compliance to participate in treatment. --The nurse practitioner will assess all [MEDICAL TREATMENT] residents for any concerns related to general health. --Physician will be immediately notified of recommendation to discontinue [MEDICATION NAME]. --All communications from [MEDICAL TREATMENT] will be reviewed for missed recommendations related to treatment to ensure that recommendations have been addressed. --All residents will be re-assessed/evaluated for pain once [MEDICAL TREATMENT] residents have been reviewed to ensure that pain is controlled. --Any concerns identified, related to pain, will be presented to the physician for review/adjustment of pain medication regimen. --The facility will immediately begin re-education on the pain process of identification, assessing, prevention, treatment, and documentation, --The facility will immediately begin education with the Nursing staff on End Stage [MEDICAL CONDITION]/[MEDICAL TREATMENT].",2017-01-01
7888,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2012-08-17,156,D,0,1,INBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate liability notices to two residents (Resident #6 and #41) out of five sampled residents reviewed for liability notices and beneficiary appeal rights. Findings Include: Resident #6 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #6 was notified by the facility that skilled nursing services would end on July 18, 2012. Notice of Medicare Non-Coverage (CMS Form ) was signed by the resident's Medical Power of Attorney on July 17, 2012. Resident #41 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #41 was notified by the facility that skilled nursing services would end on July 27, 2012. Notice of Medicare Non-Coverage (CMS Form ) was signed by the resident's Power of Attorney on August 1, 2012, 5 days after the cessation of the services on July 27, 2012. Both resident #6 and #41 remained in the facility and were not discharged following the end of covered services. However, the residents were not issued the Skilled Nursing Facility Advance Beneficiary Notice (CMS Form ) or an appropriate generic denial letter. An interview with employee #176 was conducted on August 17, 2012. Employee #176 stated that she issued the CMS Form and not the CMS Form or another appropriate Denial Letter. A subsequent interview was conducted with licensed social worker on August 17, 2012. Staff stated that she was aware of the requirements for issuing liability notices but could not locate the form in the facility's computer drive and believed that it was not the facility policy to issue any liability notices other than the CMS . A verbal policy that the facility complies with Federal requirements regarding liability notices was provided by the facility.",2016-12-01
7889,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2012-08-17,164,E,0,1,INBY11,"Based on observations and staff interview, the facility failed to provide privacy equipment in semiprivate rooms. Findings include: On 8/13/2012 and 8/14/2012, observations of resident rooms were made multiple times. Semi-private resident rooms including rooms F12, F16, B11, G14 and B4 were noted to have privacy curtains that would not enclose, and ensure the privacy of, residents in the bed closest to the door (Bed 1). The curtain left an approximately 18 inch gap that would allow anyone passing from the door to the bed closest to the window (Bed 2), or from Bed 2 to the bathroom or the door to the hall, to see a resident in Bed 1. On 8/15/2012 at 9:15 AM, an interview was completed with the Maintenance Director. The Director said that he had not heard any complaints about the privacy curtains. He acknowledged that the curtains could not enclose Bed 1. He added, 'We can extend the track and make the curtain reach.",2016-12-01
7890,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2012-08-17,225,D,0,1,INBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to thoroughly investigate alleged violations of mistreatment of [REDACTED]. Specifically, the facility could not provide evidence of a thorough investigation including interviews with residents to ensure the alleged mistreatment did not extend to other residents in the building. On 8/16/12 at 8:45 AM, the Director of Nursing (DON) provided requested investigations of abuse allegations to the surveyor to review. The DON stated, Our corporate policy dictates the investigations must include a summary of the entire event; who was talked with and the outcome of the investigation. Review of the investigations revealed only an initial statement of the complaint, a 5 day follow up with the State and witness statements. There was no summary of the investigation leading to the determination of the outcome. The following incidents were reviewed: 1. Review of the investigation related to a fracture caused during care for resident #33, revealed only staff members were required to give statements of their knowledge of the event. Residents were not asked about rough treatment by staff. There was no summary of the investigation and the required education for the 2 Certified Nurses Aides (CNA)s involved in the incident did not include abuse prevention. The clinical record for resident #33 was reviewed. Her [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] revealed resident #33 was rarely/never understood and was totally dependent on staff for all Activities of Daily Living (ADLs). She was always incontinent of both bowel and bladder. Review of the Nurses Notes (NN) revealed: On 7/25/2012 at 21:30 a General Progress Note stated, CNA's approached me and another nurse and said they were cleaning resident because she had BM in her vagina. They were trying to open her legs, and heard a pop. Assessed resident and observed a knot above left knee. Called Dr. and received order for X-ray of left femur and pelvis. On 7/25/2012 at 22:00 a General Progress Note stated, Called X-ray order in. Called POA. On 7/25/2012 at 23:53 a General Progress Note stated, X-ray tech here to obtain X-ray. Assisted X-ray tech and CNA with positioning of resident. Awaiting results. On 7/26/2012 at 02:00 a General Progress Note stated, X-ray results revealed comminuted [MEDICAL CONDITION] third of the left femoral diaphysis. No foreign bodies are seen. The soft tissues appear intact. There are [MEDICAL CONDITION] changes at the knee. Dr. aware with new orders. Send resident to emergency room (ER) for evaluation of the fracture. Per POA request, this nurse will notify her in the AM at 0630. On 7/26/2012 at 02:20 a General Progress Note stated, Report called in to hospital. EMT aware of need for transportation. Copy of X-ray results sent to hospital. On 7/26/2012 at 02:45 a General Progress Note stated, Resident leaving facility via stretcher - ambulance services. On 7/26/2012 at 06:53 a General Progress Note stated, Resident being admitted to (hospital) for femur fracture. On 8/1/2012 a nursing note documented the return of resident #33 to the facility. Review of the hospital and imaging reports revealed: History & Physical: 7/26/12 chief complaint: fracture, left femur This [AGE] year old lady is a long-term resident at the NH, Staff at the nursing home heard a pop while repositioning (resident) . X-rays confirmed a comminuted [MEDICAL CONDITION] end of the left femur. She was sent to the ER and admitted for Orthopedic consultation. Diagnostic Imaging Report: 7/26/12 Findings: There is [MEDICAL CONDITION]. There is a comminuted fracture involving the distal diaphysis of the left femur. There is slight diastases. Radiology interpretation: Comminuted [MEDICAL CONDITION] third of the left femoral diaphysis. No foreign bodies are seen The soft tissues appear intact. There are [MEDICAL CONDITION] changes at the knee. Impression: Comminuted mildly displaced [MEDICAL CONDITION] femur Witness statements: CNA #203 statement:, I was assisting the B wing CNA #59 at her request to change resident #33. I have assisted in care for her before because it is safer to use 2 aids. I placed one one hand on her shoulder and one hand on her upper thigh and turned her toward the other CNA. When CNA #59 had received my reposition I did one wipe and then heard the pop I immediately went to LPN #196 because resident #33 is contracted when I turned to wipe her I did not pull on her legs to clean her because she is contracted, so I don't ever have to or would not pull on her legs. LPN #196's statement: LPN #122 and I were on A wing when CNAs #59 and #203 approached us talking over each other, They both told us that they were cleaning resident #33 and were trying to get BM out of her vaginal area, demonstrating how they were trying to open her legs to clean her vagina, when they heard a pop We went to assess the resident and observed a raised [MEDICAL CONDITION] knot above the knee. Review of the investigative documentation revealed a timeline and details of the above incident. The summary of critical information obtained during the investigation included the following: -x-ray showed fracture of distal 3rd of L femoral diaphysis -Action taken: CNAs #59 and #203 suspended -Both were cleared to return to work on 7/31/12 on condition of returning to work, they were required to attend an in-service on positioning, turning and care of resident during ADL care. -Included in the investigation was a Staff Development Program Attendance Record detailing the topic, Maxislides and Lifts. Both CNAs signed as attending the inservice and viewing the video, dated 8/10/12. There was no evidence in the investigation revealing whether other residents were interviewed related to how staff treated them, specifically the 2 CNAs involved in this incident. There was no evidence in the investigation revealing whether other staff members were interviewed related to their knowledge of other incidents of rough treatment involving these 2 CNAs. The witness statements only addressed their knowledge of this particular incident. There was inadequate documentation in the investigation to reveal whether the CNAs had or had not treated resident #33 roughly, thus causing the fracture. Post investigation education for the CNAs included only education on transfer and lift use. It did not include abuse prohibition education or staff treatment of [REDACTED]. 2. Review of the investigation for resident #108 revealed alleged rough treatment and derogatory language used by CNA #203 as witnessed by CNA #25. Again, only staff members were required to give statements of their knowledge of the event. Residents were not asked about rough treatment or abusive language used by staff. There was no summary of the investigation revealing what the outcome was based on and the required education did not include abuse prevention. The clinical record for resident #108 was reviewed. His [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] revealed resident #108 scored a BIMS rating of 3, indicating he was not cognitively able to make daily decisions. He was totally dependent on staff for all Activities of Daily Living ( ADLs), with the exception of eating, bed mobility and toileting were he was coded as requiring extensive assistance from staff. He also had a range of motion impairment on one side. CNA# 25 had reported to RN #45 on 8/1/12 that CNA #203 was rough with resident #108 when providing care. A Resident Concern Form was completed by CNA #25 on 8/1/12. The form was provided to RN #45 and stated, CNA #25 reported to me on 8/1/12 at approximately 6:15 PM that she had witnessed CNA #203 being rough with resident #108, while #203 was orienting CNA #25. CNA #25 wrote on the Resident Concern Form, About a month ago on a weekday at approximately 4:30 PM I was on orientation. I was with CNA #203. We went into resident #108's room. CNA #203 wanted to get him up for supper. She went to pick him up and he was moaning. I said, I think we should keep him in bed. She picked him up by herself, under his arms and pivoted him towards the chair and dropped him into the chair. Resident #108 screamed, Oh God! He started hitting and moaning. I said, You hurt him. I was trying to comfort him. CNA #203 said, My give a damn left about a year ago. I used to be like you. Now I don't care if they live or die--just one less person for me to care for. She said, I'm here for a paycheck. I told her, You will be old someday. I kept comforting the resident and took him to the dining room and got help from another CNA to put him back to bed. There was someone else in the room, but I'm not sure who it was. I thought I needed to report it but I was told I had to be in the union for 30 days before I could report anything. I worked with her (CNA #203) enough to see she is very rough with the patients. Investigation Documentation: The facility reported the above Incident to the State's nurse aide registry on 8/6/12. The WV Dept of Health and Human Resources Adult Protective Service Mandatory Reporting form was also completed. The form summarized the incident as, Another CNA alleges that during her orientation on the floor about a month ago, perpetrator was rough with resident. Employee suspended during the investigation. The narrative summary of the investigative report stated: After investigation of reported incident, allegation can't be substantiated d/t untimely reporting. Abuse/neglect reporting education to be done and CNA believed to be perpetrator will have mandatory customer service training. The summary also included a signed a sheet of paper indicating that CNA #203 had watched a video on customer service. There was no evidence that either CNA received any training r/t abuse reporting and prevention. Staff Statements were also included in the investigative file. A. CNA #61 provided a witness statement on 8/8/12 stating: CNA #61 stated she knew nothing about the incident until CNA #25 talked about it. CNA #25 made comments that she wanted to leave resident in bed due to pain. CNA #203 transferred resident alone and stated to #25 I don't give a[***](because she did not want to feed resident in bed). 1. When did she tell you this? It was whatever day she came in early last week. 2. Who did she tell? (name), today. 3. What was her exact comment about the resident, I used to be just like you but my give a[***] went out the door years ago. B. LPN #158 wrote in her statement on 8/1/12 about 6:15 PM, RN #45 and I went to smoke. CNA #25 came outside and stated, I can't believe CNAs #59 and 203 are coming back. RN and I stated we were unaware they were coming back. CNA #25 stated, I had orientation with CNA #203 and she is rough. One day I had orientation with her we were taking care of resident #108 and she threw him in his w/c and said (to me), My give a damn left years ago,I don't care if these people live or die; its one less person I have to take care of. RN #45 asked if she had reported this to anyone. She was then educated on importance of reporting incidents and then RN called the DON. C. RN #45 wrote in her statement: On 8/1/12 at approximately 6:15 PM me and LPN #158 went to smoke and CNA #25 came out to sit down and said, I can't believe CNAs #59 and 203 are coming back. I said, Well I didn't know they were. CNA #25 said, Yes they are and I know how CNA #203 is and I'm surprised she is coming back. I stated I didn't know her very well, I've never had any trouble from her. CNA #25 stated, She oriented me and she is rough . I was with her one day with Resident #108 and she threw him in his chair and told me her give a damn left years ago. She didn't care if these people live or die it was one less person to take care of. I asked CNA #25 if she reported this to anyone and she stated, No I was told I couldn't report nothing until I was in the union. I told her that was not true she had to report all abuse or neglect to a supervisor. I then left the smoke shack and called the DON and reported what she had said to me. Statement by alleged perpetrator, CNA #203: Have you ever provided care to #108? Yes several times when I am float. I had him on Sunday when I came in early. Do you know how he transfers? Yes he is a mechanical lift. Have you ever picked him up and transferred him without a lift. No I always ask him if he wants to get up. Do you ever recall saying My give a damn is busted? No Do you recall ever making a comment you didn't care about a resident you were caring for. No Have you ever done orientation with new CNA? Yes, CNA #25 and CNA #43. Have you ever known of anyone else making a negative statement about a resident No Is there anyone who you have helped provide care to him? yes CNA #25. With regard to another allegation reported to administration by the surveyor on 8/14/12, Human Resources (HR) interviewed CNA #203. CNA #203's statement on 8/15/12 to HR was, I have never oriented a CNA until CNA #43, who just started last week. The 8/14/12 statement contradicted the initial statement CNA #203's had made on 8/6/12. At that time she had acknowledged orienting both CNA #25 and CNA #43. The investigation was not reported to the State within the required time frames. The allegation was made and reported to facility administration on 8/1/12, yet was not reported to the State of WV until 8/6/12, 5 days after the allegation. There was no evidence in the investigation revealing whether other residents were interviewed related to how staff, specifically CNA #203 treated them or spoke to them. There was no evidence in the investigation revealing whether other staff members were interviewed related to their knowledge of other incidents of rough treatment or derogatory language. The witness statements only addressed their knowledge of the particular incident. There was no documentation in the investigation revealing sufficient evidence to arrive at a determination that the CNA had or had not treated resident #108 roughly or used derogatory language. Post investigation education for CNA #203 included only education on customer service. It did not include abuse prevention. On 8/16/12 at 9:59 AM the surveyor attempted to interview resident #108. When asked him if he was (resident #108), he responded, Yes. The surveyor asked him if anyone ever hurt him while they were working with him. He said, Yea! and reached out to (the surveyor). He was trying to talk but the (surveyor) was not able to understand what he was saying. He appeared agitated and/or upset. The Director of Nursing (DON) was interviewed at 8:45 AM on 8/16/12. She stated she had not read the investigations r/t residents #33 or #108, At the time an (Interim NHA) was the acting Nursing Home Administrator for a couple of weeks. He didn't have the educational requirements required by the State of WV. His education was from England. He has a temporary RN license with the State of WV. He had a temporary NHA license but WV rescinded his license due to failure to meet the educational requirements of the State. When the corporation become aware of the situation, they called in the current interim NHA. She is contracted by the corporation. She started 10 days ago with a temporary contract. The DON stated neither she nor the newly acting NHA were doing [MEDICATION NAME]. The assistant NHA took over doing all the [MEDICATION NAME] and investigations until she left about a week ago. The surveyor asked the DON if her interest wasn't peaked with regard to resident #33's fracture? She stated, Well yes, but I was told (by the interim NHA) to work on other things, he would handle the investigations. In retrospect, I would liked to have been actively involved in that investigation. During the same interview with the DON at 8:45 AM on 8/16/12, the Nursing Home Administrator (NHA) stated she had a peripheral knowledge of the incident and assumed the investigations had been handled appropriately. She also supported the DON's statement that neither of them were doing [MEDICATION NAME] as the assistant NHA did all [MEDICATION NAME] and investigations after the interim NHA was relieved of his position, until she left about a week ago. The NHA continued, It appears the process dictated by the corporate structure was not followed completely. The interim administrator at the time, was found to not have the required credentials and was relieved of his position. The real investigative process is solid, unfortunately the process was not followed per corporate policies and guidelines.",2016-12-01
7891,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2012-08-17,226,D,0,1,INBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record review, the facility failed to operationalize their abuse prevention policy and procedures. Specifically: 1. The facility did not ensure staff were following stated procedures in their abuse prevention policy related to reporting of alleged violations as evidenced by the failure of Certified Nurses Aide #25 who did not report an allegation of derogatory language and rough treatment of [REDACTED]. 2. The facility failed to provide residents and staff information on who to report to, provide an environment for reporting that was free from reprisal and provide feedback for expressed concerns. Resident #43 stated in interview that she had reported allegations of rough treatment several times to staff. Not only was feedback not provided but there was no evidence that the allegations had been reported. Additionally, staff members stated they report concerns of staff treatment but nurses don't act on their allegations. The findings were: Review of the facility policy on abuse revealed, in pertinent part: Reporting without reprisal: The facility must establish an environment where staff and patients who report abuse, neglect and or misappropriation do not fear, and are protected from retaliation, both during and after any investigation into the event. The center must assure that the reporter is not looked upon negatively or receives any form of treatment that may be considered punishment. Many state protective service laws include protection of reporters from retaliation. Reporting: The center must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the center and to other officials in accordance with state law through established procedures .CMS believes immediately means as soon as possible, but ought not to exceed 24 hrs after discovery of the incident. 1. Review of the investigation for resident #108 revealed alleged rough treatment and derogatory language used by CNA #203 as witnessed by CNA #25. However the allegation was related to an incident that occurred 1 month prior to the CNA reporting it. Allegation: CNA# 25 reported to RN #45 on 8/1/12 that CNA #203 was rough with resident #108 when providing care. 8/1/12 Resident Concern Form: CNA #25 reported to RN #45 description of incident: CNA #25 reported to me on 8/1/12 app 6:15 PM that she had witnessed CNA #203 being rough with resident #108, while #203 was orienting CNA #25. CNA #25 stated, About a month ago on a weekday at approximately 4:30 PM I was on orientation. I was with CNA #203. We went into resident #108's room. CNA 203 wanted to get him up for supper. She went to pick him up and he was moaning. I said, I think we should keep him in bed. She picked him up by herself under his arms and pivoted him towards the chair and dropped him into the chair. Resident #108 screamed, Oh God! He started hitting and moaning. I said, You hurt him. I was trying to comfort him. CNA #203 said, My give a damn left about a year ago. I used to be like you. Now I don't care if they live or die--just one less person for me to care for. She said, I'm here for a paycheck. I told her, You will be old someday. I kept comforting the resident and took him to the dining room and got help from another CNA to put him back to bed. There was someone else in the room, but I'm not sure who it was. I thought I needed to report it but I was told I had to be in the union for 30 days before I could report anything. I worked with her (CNA #203) enough to see she is very rough with the patients. Investigation Documentation: Incident reported to State Nurse aide registry on 8/6/12, Incident date : unknown CNA reported to nurse on 8/1/12, then reported to administration. Allegation: CNA alleges during orientation on the floor about a month ago, perpetrator listed above (#203) was rough with resident #108, described as incapacity. WV Dept of Health and Human Resources Adult Protective Service Mandatory Reporting form: Allegation unknown date. Another CNA alleges that during her orientation on the floor about a month ago, perpetrator above was rough with resident. Employee suspended during the investigation Narrative investigative report: After investigation of reported incident, allegation can't be substantiated due to untimely reporting. Abuse/neglect reporting education to be done and CNA believed to be perpetrator will have mandatory customer service training.CNA #203 signed a sheet of paper that she has watched a video on customer service. A new employee, CNA #25 did not report an allegation for 1 month after the alleged incident occurred. She stated in interview that she was told she could not report an allegation of abuse until she had been employed for 1 month. The facility failed to ensure accurate information related to reporting of abuse allegations was provided during orientation of new employees. 2. During an interview with resident #43 on 8/13 at 11:50 am she stated CNA #59 hurt her when she was providing care for her. Asked if she reported the incident resident #43 stated, Oh yes, but no one has done anything about it. CNA #59 is still here but I won't let her work with me. She is just rough period. In a follow up interview with resident #43 on 8/15/12 at 3:30 PM, she stated, I have put in 4 complaints about CNA #59 being rough and having an attitude but she's still here. She was mouthy! I told her she worked for me--I didn't work for her! No one has followed up with me. One of those times I was really mad because they didn't act on anything. Resident #43 couldn't remember who she told, lots of staff have left. She continued, the incident that made her really mad occurred months ago. She filled out a report at the nurses station. Resident #43 was adamant and convincing in her story, I was in the bathroom and rang the buzzer. CNA #59 came in-- she wiped me and hurt me (I had a UTI) I told her she hurt me and she said she was all stressed out. I told her, Now you got me all stressed out and I have to report you. I gave the report back to the nurse at the desk. The clinical record for resident #43 was reviewed. Her [DIAGNOSES REDACTED]. The readmission Minimum Data Set (MDS)dated 7/27/12 revealed resident #43 had a BIMS score of 13, indicating she was independent in her cognitive abilities for daily decision making. She did not have any behaviors. She was scored as requiring extensive assistance for Activities of Daily Living (ADLs) frequently incontinent of bladder and always continent of bowel. The surveyor reported to the Director of Nursing on 8/13/12 at 4:30 PM the allegations made by resident #43. The DON was not aware of any concerns voiced by resident #43. The DON stated the resident had a recent cognitive decline and the MD took her capacity away when she was recently hospitalized . The DON stated she also was not aware of complaints from other residents related to CNA #59. The employee file for CNA #59 was reviewed. It did not contain any disciplinary action, except 1 action related to attendance. The DON was not able to find any reports of staff mistreatment filed by resident #43. The DON filled out the following Incident report: 8/13/12 Patient discussed concern with surveyor. Surveyor notified administration. At approx 5 PM employee (CNA #59) interviewed and suspended at 5:30 PM. The WV Adult Protective Services form was completed. Details documented included: date of incident 3-4 months ago/reported on 8/14/12. Victim alleged that CNA was rude and rough while providing care. Reported to facility staff by QIS surveyor. Resident was documented as incapacity. The patient was interviewed and stated, I reported that CNA #59 was rough with me about 4 times between now and back in January. I think it was daytime between breakfast and lunch,. I talked to the nurse and even wrote a statement once. She was rough with me. Back in Dec, I think, I had a bad UTI, CNA #59 was helping me in the bathroom. When she wiped me she was rough and caused me to bleed. She has a bad attitude all the time. I kept waiting on someone to call me or come talk to me but no one ever did. On 8/13/12 a facility Human Resources staff member interviewed resident #43 and documented the following: I have no issues at this time, but employee #59 is back. She was rough and rude. Several months ago I had a UTI and when she wiped me she hurt me. I let her know that she worked for me and I did not work for her. That girl has not taken care of me since that happened and I will never let her back in my room again. An Interview with CNA #59 related to the allegations was documented by the facility as follows: Have you ever provided care to resident #43? Not for several months. A night shift supervisor said for her to no longer to give care for resident #43. Around [DATE] I asked resident #43 if she had hemorrhoids and she told me no that (CNA# 59) caused the bleeding and I (CNA #59) immediately told my nurse (LPN #196) and another CNA provided care to her. Then a couple of months later the resident said that I told another resident to shut up. At that time RN #82 said she spoke with the resident and stated she is after your license and advised CNA #59 to no longer provide care to her. CNA denied ever being rude or rough and stated that night supervisor advised her to no longer care for resident. Asked Why would resident say she is after your license? CNA stated, I don't know, I have never had issue with her until the day regarding bleeding. Did you stop taking care of her then? That night but then I cared for her until she said that I told another staff member to shut up. The above interview leaves many questions unanswered. RN supervisor #82 informed CNA #59 not to care for resident #43 'because she is after your license, yet there was no evidence of documentation that RN supervisor #82 initiated a resident concern form or reported such to administration. LPN #196 was informed by CNA #59 that resident #43 accused her of causing bleeding when providing care. Again, neither a resident concern form was initiated nor was the situation reported to administration. On 8/14/12 the DON informed the surveyor that she had talked with resident #43 and stated, CNA #59 was suspended a short time ago. Review of the clinical record on 7/20/12 revealed the physician removed capacity, memory and judgement impaired during the hospitalization . This note followed a hospitalization where the resident experienced mental status changes with a UTI. The Licensed Social Service Worker stated on 8/15/12 at 4:00 PM that she thought resident #43's incapacity status should be restored to capacity, as it was removed when she was ill. Interviews were conducted with CNAs and nurses on 8/15/12 and 8/16/12. During those interviews 4 staff members confided in the surveyor that they frequently reported situations of concern including CNAs refusing to provide care for residents, refusing to answer call lights and suspecting that one CNA was not feeding a resident who was totally dependent on staff to eat. The CNAs requested they not be identified related to fear of losing their jobs. Staff member #A stated s/he reported verbal abuse recently but the nurses don't do anything. Staff member #B reported a staff member who, won't answer call lights because she isn't assigned to that resident. I hear call bells [MEDICATION NAME] 15-20 minutes. I reported it but nothing happened. Staff member #C, I have reported verbal abuse but nothing ever happens--Recently within the past 6 months. Staff member #D, I have reported a CNA who refuses to answer call lights. Staff member #E stated, A CNA will say she has fed a resident but the meal tray has not been touched. This has been reported. Staff member #F stated s/he has told nurses that the meal tray for a resident is often not touched but the CNA assigned to that resident says she has fed him. Nothing ever changes. I don't think they ever look into it. During interviews with the NHA and DON at 11:49 AM on 8/17/12 the surveyor raised the concern voiced by staff saying they report incidents but nothing ever happens. The DON stated staff education will be discussed at the staff meetings which she is re-instituting monthly. She is starting off with mandatory inservicing.I have an open door policy for both staff and residents. With regard to the investigations of residents #33 and 108, the DON stated she re-opened the investigations and had started interviewing the residents, concentrating first on B hall. She also stated she had also begun an investigation related to the allegations made by resident #43. The DON was interviewed again on 8/17/12 at approximately 1:00 PM. She stated, There have been so many involved with investigations of alleged violations, the Nursing Home Administrator and I will be responsible for investigations from now on. She continued that in the past there appeared to be some confusion with the many interim management positions, staff nurses, unit managers and RN supervisors, Now everyone will know who to report to me. She stated she had a staff meeting planned and would be discussing reporting of abuse allegations and staff treatment of [REDACTED]. During the same interview on 8/17/12 at 1:00 PM the NHA stated, Resident advocacy education and implementation will be a priority. Supporting people from beneath rather than above values people and instills pride in their work. Recognizing burnout and healing it is also important.",2016-12-01
7892,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2012-08-17,248,D,0,1,INBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and staff interviews, the facility failed to provide an individualized activity program for 2 of 3 cognitively impaired residents reviewed of 7 residents with potential activity concerns (Residents #144 and #328). Findings include: 1. Resident #328 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Resident #328's Care Plan dated 7/25/2012 noted interventions to ensure she was involved in activity programs. Interventions included: (1) arrange for seating closer to leader of activity programs as patient is hard of hearing; (2) Assist in planning and/or encourage to plan own leisure time activities; (3) Assist to transport to & from activities of choice; and, (4) Encourage participation in group activities of interest. Review of a nursing admission note dated 7/23/2012 revealed, [AGE] year old female recently admitted after an acute care hospitalization r/t (related to) dx.(diagnosis) of [MEDICAL CONDITION], probably secondary to SIADH (syndrome of inappropriate antidiuretic hormone secretion); HTN; [MEDICAL CONDITION]; abdominal aortic aneurysm 4.6 cm, conservative treatment only; and hx. (history) of [MEDICAL CONDITION]. Pt .(patient) has dementia, she has difficulty with sequencing, staying on task, or completing tasks. Requiring frequent cueing. Review of the Daily Recreation/Activity Participation document for July and August 2012 for Resident #328 noted that daily Resident #328 was independent in socializing. No other programs were marked as having occurred. Options to mark included reading, sensory stimulation and television. There were no narrative notes written by activity staff on the form. The review was done on 8/15/2012 at 3:40 PM. On 8/15/2012 at 10:55 AM, an interview was completed with Nursing Assistant #96 (NA# 96). NA #96 stated that she was familiar with Resident # 328. She is very confused We have taken her to church. When she has gone to church, she has gotten wound up and we've had to bring her back. NA# 96 said that she was not aware of any other activities that Resident #328 has been involved in. She also stated that she thinks the activities staff, go in, I guess every couple weeks, to see her. An interview was completed with Activity Assistant #194 (AA# 194) on 8/15/2012 at 3:15 PM. AA# 194 said, On admission, there is an activity assessment and a care plan. (Activity Director-AD #99) will tell us what is in the care plan. We chart on paper when things come up or are different. We keep a log of the resident's participation. We mark if they are active. If they don't come to activities, we let them know what is going on and if they have a special interest, we try to accommodate that. We do 1 to 1 visits for residents who are confused. She's really confused. She doesn't come out to activities. I don't think she could do things in activities if she did come out. She doesn't get 1 on 1 because she goes to therapy. We try to focus on those that don't get out at all. On 8/15/2012 at 3:34 PM, an interview was completed with AA #109. AA #109 stated that she was familiar with Resident #328. She goes to therapy so she is out of her room a lot. I don't recall her coming to the group things. We have gone in to visit. We would talk to her, but sometimes she just starts talking about something totally different. We try to bring her back, but you may just have to go with her conversation. An interview was completed with AD #99 on 8/15/2012 at 3:40 PM. AD #99 said, I visit with her once or twice a day. She is confused and gets agitated if you are in there too much. She really likes to read. Her vision isn't very good so I give her large print or read to her. The activity staff goes in every room twice a day with the hydration cart. We spend time with all of the residents then. On 8/16/2012 at 10:15 AM, AA #109 was observed going to Resident #328's room with hydration. AA #109 offered Resident #328 something to drink. Resident #328 asked AA #109 to call a family member for her. AA #109 said that she would try, and left the room. At 10:25 AM, AA #109 returned and told Resident #328 that the social worker would try to make the call and would be in touch with the resident. AA #109 told Resident #328 that she would check back with her. A follow up interview was completed with AA #109 on 8/17/2012 at 9:45 AM. AA #109 said that she marked Resident #328 as independently socializing on the participation form on 8/16/2012 after the conversation on 8/16/2012 at 10:15 AM. 2. Resident #144 was admitted to the facility on [DATE]. Review of an activities evaluation dated 7/24/2012 noted that Resident #144 had an interest in animals, children, current events, music, outdoor activities, socials, puzzles/games, reading, talking, religion and television. Review of the care plan dated 7/31/2012 noted the following interventions for activities: encourage to plan her own leisure time activities, assist to transport to activities, encourage participation in group, offer activities with patient's known interests and supply large print material. Resident #144 also had a care plan for cognitive loss. Review of the Daily Recreation/Activity Participation document for July and August 2012 for Resident #144 noted that daily Resident #144 was independent in socializing. No other programs were marked as having occurred. Options to mark included reading, sensory stimulation and television. There were no narrative notes written by activity staff on the form. The review was done on 8/15/2012 at 3:40 PM. An interview was completed with Nurse #126 on 8/14/2012 at 3:48 PM. Nurse #126 stated that she was familiar with Resident #144. Nurse #126 said that she did not think that Resident #144 goes out of her room for any activities. She is confused most the time but is not combative. An interview was completed with Nursing Assistant #33 (NA #33) on 8/15/2012 at 8:38 AM. NA #33 stated she was familiar with Resident #144. (Resident #144) usually doesn't want to go to activities. She isn't confused. I haven't seen activities (staff) down to her room. On 8/15/2012 at 10:45 AM, an interview was completed with Nursing Assistant #96 (NA #96). NA #96 stated that she was familiar with Resident #144. She is confused at times. (Resident #144) Does not go out of the room. Sometimes she refuses to get up. She watches TV but does not go out to activities. NA #96 said that she had seen activity staff go into Resident #144's room, but was not sure what they do. An interview was completed with Activity Assistant #194 (AA# 194) on 8/15/2012 at 3:15 PM. AA# 194 said, On admission, there is an activity assessment and a care plan. (Activity Director-AD #99) will tell us what is in the care plan. We chart on paper when things come up or are different. We keep a log of the resident's participation. We mark if they are active. If they don't come to activities, we let them know what is going on and if they have a special interest, we try to accommodate that. We do 1 to 1 visits for residents who are confused. AA #194 stated that she was not very familiar with Resident #144. She doesn't come out. We don't do one on one with her. I haven't talked to her but (AA # 109 and AD #99) have. On 8/15/2012 at 3:25 PM, an interview was completed with AA # 109. AA# 109 said, If a resident doesn't come out (of their room), we may do a 1 to 1. We encourage them to come out or they can do individual activities. (Resident #144) doesn't come to any activities that I can recall. She is more independent, we don't really do one on one with her. I wouldn't say she has a lot of confusion. AA #109 said that she was not sure if Resident #144 could make her interests known. An interview was completed with AD #99 on 8/15/2012 at 3:40 PM. AD #99 said that Resident #144 stays in her room a lot. She may be transitioning to long term (placement). We visit them (the residents) twice a day during hydration rounds. They (activity assistants) interact with every resident twice a day. (Resident #144) is not as confused, but she is a private person. When residents come in, I do the assessment and set up the care plan. If something changes with the resident, (AA #109 or #194) will let me know and I fill out a 24 hour report. I share that in the morning meeting. On 8/16/2012 at 10:35 AM, AA #109 was observed providing hydration. AA #109 spoke with Resident #144 about how she was. Do you need anything? AA #109 told Resident #144 about group activities for the day and spent a few minutes asking the resident how to spell Supercalifragilisticexpialidocious.",2016-12-01
7893,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2012-08-17,280,E,0,1,INBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews, the facility failed to update care plans for 3 of 38 sampled residents (#s 68, 328, and 144). Findings include: 1. Resident #68 was admitted to the facility on [DATE]. Review of Resident #68's medical record revealed that she fell transferring herself from the chair to the Bedside Commode (BSC) on 7/28/2012 at 9:05 PM. Review of Resident #68's care plan dated 6/12/2012, noted that she was at risk for falls. Resident #68's Care Plan had interventions including encouraging the resident to transfer slowly and reinforcing the need to call for assistance. On 7/29/2012, Resident #68's care plan was updated. A second, separate fall risk potential was listed. Interventions included: assist with transfer to the BSC, keep BSC closer to the bed and encourage to notify staff of transfers. An observation of Resident #68's room was completed on 8/16/2012 at 1:30 PM. No BSC was noted to be in the room. An interview was completed with Resident #68 on 8/16/2012 at 1:30 PM. Resident #68 said that she did not remember falling. When asked about the BSC, she stated she thought she remembered having a commode at one time. They took it for some reason. I use the walker by myself and get to the bathroom. An interview was completed with Nursing Assistant #32 (NA #32) on 8/15/2012 at 2:35 PM. NA #32 stated that she was familiar with Resident #68. Her memory is ok but she forgets sometimes. NA #32 said that she was not aware of Resident #68 having had a fall. She doesn't get up by herself. She uses her call light and we help her with the walker to the bathroom. If Resident #68 did fall, it would really be an accident. If there was a fall I would hear it in report If it was days ago the resident would tell me or the nurse might tell me. On 8/17/2012 at 9:35 AM, an interview was completed with NA # 118. NA #118 said that she was familiar with Resident #68 and that she was not aware of any falls for Resident #68. She is continent most of the time. She calls us if she needs to go. We have to help her stand and she uses the walker by herself. She did have a BSC. We took it out when she was able to walk to the bathroom. She isn't confused at all. If there had been a fall when I wasn't here, the nurse would tell me. I ask the nurse what happened while I was gone. NA #118 said that there was no signage used to indicate which residents were at risk for falls. 2. Resident #68 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Resident #68 had a nutritional assessment dated [DATE]. No other nutritional assessments were found. Review of a Nutrition Note dated 7/18/2012 revealed: Weight evaluation: Current weight is 176 (pounds) which is a dec (decrease) of 8.6% x 30 (days); (Resident #68) had a weekly weight of 188.8 (pounds) on 6/26 (2012). Will monitor her weekly weights; also may benefit from mvi/minerals (multivitamin) to better meet nutrient needs. Review of Resident #68's care plan revealed a focus for weight loss dated 7/20/2012. The goal was to have Resident #68 maintain her weight. Interventions included supplementing with vitamins and to honor food preferences. There was no documentation on the care plan to perform weekly weights. No other updates to Resident #68's nutrition care plan were provided. Recorded weights for Resident #68 were reviewed. On 6/26/2012, Resident #68 had a recorded weight of 188.8 pounds, on 7/02/2012, the recorded weight was 176.0; 7/25/2012 the weight was 171.8 and on 8/15/2012, the recorded weight was 169.0. An interview was completed with the Registered Dietitian (RD # 139) on 8/17/2012 at 10:15 AM. RD #139 said that Resident #68, had some weight loss and she had some weights that had to be redone. She should still be on weekly weights. I know who is supposed to be on weekly weights. I know she wasn't being done. A follow up interview was completed with RD #139 on 8/17/2012 at 11:25 AM. RD #139 stated, I don't update the care plans. If I make recommendations, I put them on the 24 hour report that goes to the morning meeting. My recommendations are taken from the 24 hours report and added to the care plan by someone else. 3. Resident #328 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Resident #328's Care Plan dated 7/25/2012 noted interventions to ensure she was involved in activity programs. Interventions included: (1) arrange for seating closer to leader of activity programs as patient is hard of hearing, (2) assist in planning and/or encourage to plan own leisure time activities (3) assist to transport to & from activities of choice and (4) encourage participation in group activities of interest Review of a nursing Admission note dated 7/23/2012 revealed, [AGE] year old female recently admitted after an acute care hospitalization r/t (related to) dx.(diagnosis) of [MEDICAL CONDITION], probably secondary to SIADH (syndrome of inappropriate antidiuretic hormone secretion); HTN; [MEDICAL CONDITION]; abdominal aortic aneurysm 4.6 cm, conservative treatment only; and hx. (history) of [MEDICAL CONDITION]. Pt. (patient) has dementia, she has difficulty with sequencing, staying on task, or completing tasks. Requiring frequent cueing. On 8/15/2012 at 10:55 AM, an interview was completed with Nursing Assistant #96 (NA# 96). NA #96 stated that she was familiar with Resident # 328. She is very confused We have taken her to church. When she has gone to church, she has gotten wound up and we've had to bring her back. NA# 96 said that she was not aware of any other activities that Resident #328 has been involved in. She also stated that she thinks the activities staff go in I guess every couple weeks to see her. An interview was completed with Activity Assistant #194 (AA# 194) on 8/15/2012 at 3:15 PM. AA# 194 said, On admission, there is an activity assessment and a care plan. (Activity Director-AD #99) will tell us what is in the care plan. We chart on paper when things come up or are different. We keep a log of the resident's participation. We do 1 to 1 visits for residents who are confused. She's really confused. She doesn't come out to activities. I don't think she could do things in activities if she did come out. On 8/15/2012 at 3:34 PM, an interview was completed with AA #109. AA #109 stated that she was familiar with Resident #328. She goes to therapy so she is out of her room a lot. I don't recall her coming to the group things. We have gone in to visit. We would talk to her, but sometimes she just starts talking about something totally different. We try to bring her back, but you may just have to go with her conversation. An interview was completed with AD #99 on 8/15/2012 at 3:40 PM. AD #99 said, I visit with her once or twice a day. She is confused and gets agitated if you are in there too much. She really likes to read. Her vision isn't very good so I give her large print or read to her. The activity staff goes in every room twice a day with the hydration cart. Resident #328 was not observed participating in any activity outside the room during the survey. 4. Resident #144 was admitted to the facility on [DATE]. Review of an activities evaluation dated 7/24/2012 noted that Resident #144 had an interest in animals, children, current events, music, outdoor activities, socials, puzzles/games, reading, talking, religion and television. Review of the care plan dated 7/31/2012 noted the following interventions for activities: encourage to plan her own leisure time activities, assist to transport to activities, encourage participation in group, offer activities with patient's known interests and supply large print material. Resident #144 also had a care plan for cognitive loss. Review of the Daily Recreation/Activity Participation document for July and August 2012 for Resident #144 noted that daily, Resident #144 was independent in socializing. No other programs were marked as having occurred. Options to mark included reading, sensory stimulation and television. There were no narrative notes written by activity staff on the form. The review was done on 8/15/2012 at 3:40 PM. An interview was completed with Nurse #126 on 8/14/2012 at 3:48 PM. Nurse #126 stated that she was familiar with Resident #144. Nurse #126 said that she did not think that Resident #126 goes out of her room for any activities. She is confused most of the time but is not combative. An interview was completed with Nursing Assistant #33 (NA #33) on 8/15/2012 at 8:38 AM. NA #33 stated she was familiar with Resident #144. (Resident #144) usually doesn't want to go to activities. She isn't confused. I haven't seen activities (staff) down to her room. On 8/15/2012 at 10:45 AM, an interview was completed with Nursing Assistant # 96 (NA #96). NA #96 stated that she was familiar with Resident #144. She is confused at times. (Resident #144) Does not go out of the room. Sometimes she refuses to get up. She watches TV but does not go out to activities. NA #96 said that she had seen activity staff go into Resident #144's room, but was not sure what they do. An interview was completed with Activity Assistant #194 (AA# 194) on 8/15/2012 at 3:15 PM. AA# 194 said, On admission, there is an activity assessment and a care plan. (Activity Director-AD #99) will tell us what is in the care plan. We chart on paper when things come up or are different. We keep a log of the resident's participation. AA #194 stated that she was not very familiar with Resident #144. She doesn't come out. We don't do one on one with her. I haven't talked to her but (AA # 109 and AD #99) have. On 8/15/2012 at 3:25 PM, an interview was completed with AA # 109. AA# 109 said, If a resident doesn't come out (of their room), we may do a 1 to 1. We encourage them to come out or they can do individual activities. (Resident #144) doesn't come to any activities that I can recall. She is more independent, we don't really do one on one with her. I wouldn't say she has a lot of confusion. AA #109 said that she was not sure if Resident #144 could make her interests known. An interview was completed with AD #99 on 8/15/2012 at 3:40 PM. AD #99 said that Resident #144 stays in her room a lot. She may be transitioning to long term (placement). (Resident #144) is not as confused, but she is a private person. When residents come in, I do the assessment and set up the care plan. If something changes with the resident, (AA #109 or #194) will let me know and I fill out a 24 hour report. I share that in the morning meeting. Resident #144 was not observed outside her room for any activity during the survey.",2016-12-01
7894,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2012-08-17,309,D,0,1,INBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well- being for 1 of 10 residents whose medication regimen was reviewed. (Resident #120) Specifically, the facility failed to follow physician orders [REDACTED]. Findings include: The clinical record for resident #120 was reviewed. His [DIAGNOSES REDACTED].>[MEDICAL CONDITIONS], pain and diabetes. He was admitted to the facility on [DATE]. Review of the physician orders [REDACTED]. The Sliding Scale coverage was ordered at: 0-200 mg/dl = 0 units 201-300 mg/dl = 5 units 301-400 mg/dl =10 units Further orders were to notify the physician for blood glucose levels greater than 400 mg/dl or less than 60 mg/dl. Review of the Medication Administration Records (MARs) for May through August 2012 revealed the following 4 blood glucose levels which were outside of the ordered established parameters: 5/21/12 blood sugar level was 483 7/26/12 blood sugar level was 422 7/17/12 blood sugar level was 59 8/14/12 blood sugar level was 511 Review of nurses notes did not reveal evidence of documentation that the physician had been notified of the above levels. The Director of Nursing was interviewed on 8/16/12 at approximately 10:00 am and asked about physician notification for the above BS levels. Later in the day on 8/16/12, the DON stated she had also been unable to find notifications to the physician. She stated the physician orders [REDACTED]. The DON informed the surveyor on 8/17/12 at 1:00 pm that she would be in-servicing the nurses on following physician orders, specifically regarding blood glucose levels.",2016-12-01
7895,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2012-08-17,325,D,0,1,INBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that 1 of 3 residents reviewed (#68) out of 9 residents with nutritional concerns, maintained adequate nutritional parameters. Resident #68 was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. Recorded weights for Resident #68 were reviewed. On 6/26/2012, Resident #68 had a recorded weight of 188.8 pounds, on 7/02/2012, the recorded weight was 176.0; on 7/25/2012 the weight was 171.8 and on 8/15/2012, the recorded weight was 169.0. The weight log listed NA where other weekly weights would be recorded. Review of a Nutrition Note dated 7/18/2012 revealed: Weight evaluation: Current weight is 176 (pounds) which is a dec (decrease) of 8.6% x 30 (days); (Resident #68) had a weekly weight of 188.8 (pounds) on 6/26 (2012). Recommend change diet to regular; she receives ice cream at 8pm (8:00 PM) per staff. Will monitor her weekly weights; also may benefit from mvi/minerals (multivitamin) to better meet nutrient needs. Review of Resident #68's care plan revealed a focus for weight loss dated 7/20/2012. The goal was to have Resident #68 maintain her weight. Interventions included supplementing with vitamins and honor food preferences. There was no documentation on the care plan to perform weekly weights. No other updates to Resident #68's nutrition care plan were provided. An interview was completed with Nursing Assistant #118 (NA #118) on 8/17/2012 at 9:33 AM. NA #118 stated that she was familiar with Resident #68. She feeds herself. We set her up. For breakfast she does about 50%. Lunch she does 50-75%. I weigh her. NA #118 said she was not sure if Resident #68 had lost any weight. An interview was completed with the Dietitian (RD #139) on 8/17/2012 at 10:15 AM. RD #139 said that Resident #68, had some weight loss and she had some weights that had to be redone. I talked to her yesterday, but didn't document anything. Her appetite has been good as of late (Resident #68) said. Normally, I get the 30 day weight loss report first and try to chart on them in 2 or 3 days. RD #139 was not sure if the delay was getting the weights in the computer or when she had gotten a chance to address the weight loss. There's no way to know. She should still be on weekly (weights). I know who is supposed to be on weekly weights. I know she wasn't being done. If it's not done, I would tell the DCD (Director of Care Delivery). It would be (Nurse #23) on that unit. I hand out a sheet every week that shows who is on weekly weights. I give that to the DCDs. RD #139 also said that the note she made dated 7/18/2012 was in reference to the weight that was dated 7/02/2012. On 8/17/2012 at 10:40 AM, an interview was completed with Nurse #23. Nurse #23 said, I get a list of the weights that have to be done weekly. They (nursing assistants) give me the weights back and I see if they are done. (RD #139) hasn't talked to me about missing weights. A follow up interview was completed with RD #139 on 8/17/2012 at 11:25 AM. RD #139 stated, I don't update the care plans. If I make recommendations, I put them on the 24 hour report that goes to the morning meeting. They get taken off of there and get put on the care plan by someone. While sharing concerns on 8/17/2012 at 11:30 AM, the Nurse Consultant stated that weight monitoring was an issue that the facility had identified through the quality assurance process. She stated that the facility was working through some staffing issues in an attempt to identify specific staff to consistently weigh residents. Documentation showed weights to be a known issue since May 2012.",2016-12-01
7896,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2012-08-17,334,D,0,1,INBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer the pneumoccocal vaccine to 1 resident (#52) out of 5 residents reviewed for immunizations. Resident #52 was admitted on [DATE], with [DIAGNOSES REDACTED]. Clinical record review failed to reveal evidence that resident #52 was administered or offered the pneumoccocal vaccine. Review of an annual Minimum Data Set (MDS) dated [DATE], revealed that the resident's pneumoccocal vaccination was not up to date and the reason was that the resident was not offered the pneumoccocal vaccination. Review of facility policy regarding pneumoccocal immunizations revealed that residents would be screened for pneumonia vaccine and offered if eligible.",2016-12-01
7897,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2012-08-17,428,D,0,1,INBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to take action in response to drug irregularities identified by the consultant pharmacist during review of the drug regimen for 2 (#43 & #120 ) of the 10 residents whose medication regimens were reviewed. Findings include: The clinical record for resident #43 was reviewed. Her [DIAGNOSES REDACTED]. 1. During review of resident #43's drug regimen the following pharmacy recommendations were noted: A. On 5/16/12 the following note was written by the pharmacist: Resident is using Restoril and Trazodone for insomnia. Please evaluate need for both. The recommendation written was: Trial discontinuation of Temazepam (Restoril). Review of the Computerized Physician order [REDACTED].#43 was still taking the medication Restoril. There was no evidence on the documentation that the physician had taken action and/or signed the pharmacy recommendation. B. Also on 5/16/2012 the pharmacist had noted that a Gradual Dose Reduction (GDR) was due for the antidepressant Citalopram (Celexa), which the resident was receiving daily at 40 mg. The pharmacist's recommendation stated, Please consider GDR, while concurrently monitoring for re-emergence of depressive and or withdrawal symptoms. Review of the August 2012 Computerized Physician order [REDACTED]. There was no evidence on the documentation that the physician had taken action and/or signed the pharmacy recommendation. C. A follow-up/2nd request was noted by the pharmacist on 8/14/12, which stated, Receiving Citalopram (Celexa) 40 mg qd for management of depressive symptoms and GDR is due. Recommendation: Please consider a GDR, perhaps to 30 mg qd, while concurrently monitoring for re-emergence of depressive and/or withdrawal symptoms. Review of the August 2012 Computerized Physician order [REDACTED]. There was no evidence on the documentation that the physician had taken action and/or signed the pharmacy recommendation. D. A pharmacy recommendation dated 6/20/12 stated, Trazodone 50 mg for insomnia and a GDR is due. Recommendation: Please consider dose reduction to 25 mg q HS. Review of the August 2012 Computerized Physician order [REDACTED]. There was no evidence on the documentation that the physician had taken action and/or signed the pharmacy recommendation. 2. The clinical record for resident #120 was reviewed. His [DIAGNOSES REDACTED].>CVA, chronic renal failure, pain and diabetes. He was admitted to the facility on [DATE]. During review of resident #120's drug regimen the following pharmacy recommendations were noted: On 7/12/12 a pharmacy note stated, Resident received simvastatin and his recent lipid profile was cholesterol 84, LDL 36, HDL 31 and TG 60. Recommendation: Please consider decreasing simvastatin to 10 mg po qd. Review of the August 2012 Computerized Physician order [REDACTED]. There was no evidence on the documentation that the physician had taken action and/or signed the pharmacy recommendation. The Director or Nursing (DON) was interviewed on 8/16/12 at 10:20 AM. The DON stated, We had identified this as a system problem in June. In either June or July the medical director addressed it through the QA committee. Currently I am backtracking to ensure the recommendations were addressed. The consultant pharmacist stated on 8/17/12 at 1:15 PM that he was surprised that the recommendations had not been acted upon by the physicians.The DON identified the lack of follow-through and we came up with a plan. We reprinted the recommendations and started over contacting the physicians to ensure the recommendations had been communicated. We found that the nurses were calling the recommendations to the doctors but the facility wasn't getting the physician's signature. We still have some back log. Current plan is I will do 100% audit and we will start fresh to address pharmacy recommendations.",2016-12-01
7898,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2012-08-17,431,D,0,1,INBY11,"Based on observations and staff interviews, the facility failed to ensure drug vials were dated when opened and disposed of on or before the expiration dates. Findings include: On 8/14/2012 at 2:45 PM, the medication cart for the C Hall was examined. A bottle of Humulin R insulin was noted to be open, but not dated. On 8/14/2012 at 3:00 PM, an interview was completed with the facility pharmacist. The pharmacist said, Once in a while, I look through the stock, but (contract pharmacy) has someone who does it once a month. On 8/14/2012 at 3:09 PM, the medication cart for the F Hall was examined. One bottle of Lantus insulin was noted to be open and dated 7/14 (2012). The package insert noted that Lantus should be discarded 28 days after the vial is opened. A bottle of Humulin R insulin was dated as being opened on 7/01 (2012). The package insert noted that Humulin R should be discarded 31 days after being opened. On 8/14/2012 at 3:15 PM, the medication cart for the E Hall was examined. An open bottle of Lantus insulin was found to be undated. During an interview at this time, Nurse #237 stated that the open bottle of Lantus should have been dated.",2016-12-01
7996,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-11-27,504,D,1,0,T2IR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that laboratory services were provided to residents as ordered by the physician. During a medical record review, it was noted the physician had ordered a complete blood count (CBC), however the facility's laboratory services collected and performed a comprehensive metabolic panel (CMP). This practice was found to affect one (1) of thirteen (13) residents reviewed during a complaint investigation. Facility census: 136 Resident identifier: #137 Findings include: a) Resident #137 During a medical record review, on 11/26/13 at 10:30 a.m., it was found the physician had written an order on 09/30/13 for a CBC to be collected on 10/01/13. The laboratory results could not be located for the CBC. In an interview on 11/26/13 at 4:15 p.m., the director of nursing (DON) stated she was unable to locate the CBC results. She was able to locate results for a CMP that was collected on 10/01/13. She had a copy of the lab requisition that requested a CMP and the laboratory tracking tool that the laboratory technician signed that a CBC had been ordered, the location of the needle stick, and the color of tube the blood was collected in. The lab was collected in a [MEDICATION NAME] colored tube which she stated was the color for a CBC. She said she had made a call to the lab and was awaiting a return call. She stated the error should have been realized when the lab was returned to the facility that evening when the nurse checked off the results against the lab tracking tool. She stated the process did not work in this case. .",2016-11-01
8072,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-10-18,272,D,1,0,9VKJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the accuracy of the minimum data set (MDS) assessment for one (1) of four (4) sample residents. The nutrition status/diet section on the MDS for Resident #16 was coded incorrectly. Resident identifier: #16. Facility census: 133. Findings include: a) Resident #16 On 10/17/13 at 2:00 p.m., review of the resident's MDS, with an assessment reference date (ARD) of 10/04/13, found the resident was coded as having had a weight loss. Section K, item K0300 of the MDS was coded to indicate the resident was on a physician-prescribed weight loss regimen. Review of the physician's orders [REDACTED]. Further review of the medical record, on 10/17/13 at 2:00 p.m., found a progress note by the registered dietitian. The dietitian identified the resident had a weight loss, but was not on a physician-prescribed weight loss regimen. Interview with Employee #77, the director of nursing (DON), confirmed the resident was not on a physician-prescribed weight loss regimen. She confirmed the assessment was not accurate.",2016-10-01
8073,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-10-18,273,D,1,0,9VKJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a minimum data set (MDS) assessment for one (1) of four (4) sample residents was conducted within the required fourteen (14) calendar days after admission to the facility. Resident identifier: #2. Facility census: 133. Findings include: a) Resident #2 Review of the resident's medical record, on 10/18/13 at 10:15 a.m., found the resident was admitted to the facility on [DATE]. Further review of the medical record, on 10/18/13 at 10:15 a.m., found an MDS, with an assessment reference date (ARD) of 10/10/13, in which Sections C, D, E, and Q were blank. In addition, sections V and Z were incomplete. In an interview with Employee #77, the director of nursing (DON), on 10/18/13 at 10:30 a.m., she confirmed the MDS was incomplete and should have been completed by 10/16/13.",2016-10-01
8074,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-10-18,278,D,1,0,9VKJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the minimum data set (MDS) assessment, for one (1) of four (4) sampled residents reviewed, accurately reflected the resident's status. The MDS for this resident was certified accurate by the appropriate qualified health professional; however, the assessment was not accurate. Resident #16 was coded inaccurately concerning nutritional status. Resident identifier: #16. Facility census: 133. Findings include: a) Resident #16 On 10/17/13 at 2:00 p.m., review of the resident's MDS, with an assessment reference date (ARD) of 10/04/13, found the resident was coded as having had a weight loss. Section K, item K0300 of the MDS was coded to indicate the resident was on a physician-prescribed weight loss regimen. Review of the physician's orders [REDACTED]. Further review of the medical record, on 10/17/13 at 2:00 p.m., found a progress note by the registered dietitian. The dietitian identified the resident had a weight loss, but was not on a physician-prescribed weight loss regimen. Interview with Employee #77, the director of nursing (DON), confirmed the resident was not on a physician-prescribed weight loss regimen. She confirmed the assessment was not accurate.",2016-10-01
8075,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-10-18,280,D,1,0,9VKJ11,"Based on record review and staff interview, the facility failed to revise the care plan for one (1) of four (4) sample residents to reflect changes in the resident's condition. The care plan/interventions for maintenance of weight for Resident #28 were not revised after the resident experienced a weight loss. Resident identifier: #28. Facility census: 133. Findings include: a) Resident #28 Medical records, reviewed on 10/18/13 at 12:30 p.m., disclosed a weight of 131.2 pounds (#) on 09/03/13 for this resident. On 10/08/13, the resident's weight was 123.4#. This was a loss of 6.1% (8#) in thirty (30) days, and 11.7% (16.3#) in 180 days. Each of these significant weight losses were recognized by the registered dietitian on 10/08/13. Review of the resident's current care plan revealed a problem onset was noted on 04/16/13 stating, Nutritional status as evidenced by actual/potential weight loss/gain related to dementia and variable po (by mouth) intake. The care plan contained nothing regarding the resident's significant weight loss which was identified by the registered dietitian on 10/08/13. These findings were presented to Employee #77, the director of nursing (DON), on 10/18/13 at 1:30 p.m. The DON confirmed the care plan had not been revised to accurately reflect the weight loss and current needs of the resident.",2016-10-01
8076,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-10-18,514,D,1,0,9VKJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the medical record for one (1) of four (4) sample residents was accurate and complete. A verbal order was not transcribed to the physician's orders [REDACTED].#126. Facility census: 133. Findings include: a) Resident #126 1) Review of medical records, on 10/18/13 at 2:00 p.m., revealed a physician's orders [REDACTED]. Further review of medical records, on 10/18/13 at 2:00 p.m., found a nurse's note written by Employee #82, registered nurse (RN) which included, Patient resting well this shift with no signs of auditory hallucinations noted or reported. [MEDICATION NAME] order on hold at pharmacy pending review per consultant psychiatrist d/t (due to) multiple possible drug interactions. Interview on 10/18/13 at 2:45 p.m. with Employee #77, the director of nursing (DON), confirmed the nurse failed to transcribe a verbal order to hold the [MEDICATION NAME] as directed by the consultant psychiatrist. 2) Review of medical records, on 10/18/13 at 2:00 p.m. found a physician's orders [REDACTED].#38, a registered nurse (RN). The order was written, Change [MEDICATION NAME] 50 mg (milligrams) Q (every) 6 (six) hours dx. (diagnosis) pain. On 10/18/13 at 2:00 p.m., review of the Medication Administration Record [REDACTED]. Both [MEDICATION NAME] and [MEDICATION NAME] are pain medications. An interview on 10/18/13 at 2:45 p.m. with Employee #77, the director of nursing (DON), confirmed the incorrect medication was on the physician's orders [REDACTED]. The DON verified the correct medication was [MEDICATION NAME] and not [MEDICATION NAME].",2016-10-01
8077,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-10-29,225,E,1,0,L81Y11,"Based on record review and staff interview, the facility failed to report all allegations of abuse and neglect to the appropriate State agencies in accordance with State law. This was found for five (5) of 146 Concern Forms reviewed for the previous three (3) months. Allegations of abuse/neglect that were not reported to the required State agencies were identified for Residents #55, #59, #93, #32 and #80. Additionally, there was no evidence an investigation had been conducted for the incident concerning Resident #93. Resident Identifiers: #55, #59, #93, #32, and #80. Facility Census: 136. Findings include: a) The facility Concern Forms for the previous three (3) months were reviewed at 9:38 a.m. on 10/01/13. The following incidents were noted to not have been reported to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), or the Ombudsman and one had no evidence an investigation of the incident: 1) Resident #93 On 08/31/13 a Concern Form was completed in regards to Resident #93. The concern was (typed as written), Housekeeper reported that on Monday she heard resident say that CNA (CNA's First Name) was hurting her legs with over bed table. There was no evidence this incident had reported to the required State agencies, nor was there evidence the incident had been investigated. The Customer Service Liaison (CSL), Employee #130, was interviewed at 1:36 p.m. on 10/01/13. The CSL confirmed this allegation was not reported to OHFLAC, APS or the Ombudsman. She stated the final decision as to what to report was not hers to make. She reported the administrator made the final decision. She was unsure why this allegation was not reported. Employee #5, was interviewed at 2:12 p.m. on 10/01/13. He stated, There was an investigation into this and I will have to find it for you. Employee #5 was not able to produce documentation verify this allegation had been investigated or reported. 2) Resident #55 On 08/17/13, a Concern Form was completed regarding Resident #55. The concern was (typed as written), Resident stated that call bell was ringing for 30 minutes. No one answered fell in bathroom. Crawled to bed and got in bed herself. The CSL, Employee #130, was interviewed at 1:36 p.m. on 10/01/13. The CSL confirmed this allegation was not reported to OHFLAC, APS or the Ombudsman. She reported she was not sure why this allegation was not reported. Employee #5, the person in charge (Administrator), was interviewed at 2:12 p.m. on 10/01/13. He reported everyday they have a conference call with corporate at which time they review the concerns and the final decision to report or not to report is made. He stated, in regards to Resident #55, If the decision had been solely my decision we would have reported this as an allegation of neglect. 3) Resident #59 The facility Concern Forms for the previous three (3) months were reviewed at 9:38 a.m. on 10/01/13. On 08/22/13 there was Concern Form completed in regards to Resident #59. The concern was (typed as written), Resident was rolling in hallway in the floor and 2 nurses picked her up by under arms and drug her back into her room. There was no evidence this allegation was reported to OHFLAC, APS, or the Long Term Care Ombudsman as required by State law. The CSL, Employee #130, was interviewed at 1:36 p.m. on 10/01/13. The CSL confirmed this allegation was not reported to OHFLAC, APS or the Ombudsman. She did state she felt this was an allegation of abuse and should have been reported. Employee #5, the person in charge (Administrator), was interviewed at 2:12 p.m. on 10/01/13. He stated, The Resident does not walk and the staff should have used a mechanical lift to transfer her back to bed. He did not feel this was an allegation of abuse or neglect. He felt the aides were in a big hurry to get her back to her room and did it in the wrong fashion. 4) Resident #32 The facility Concern Forms for the previous three (3) months were reviewed at 9:38 a.m. on 10/01/13. On 09/18/13 there was a Concern Form completed in regards to Resident #32. The concern was (typed as written, Resident was documented as found with dried BM (bowel movement) on hands, face, arms and mouth. A review of the reportable incidents for the previous three (3) months, on 10/01/13, revealed this allegation was not reported to OHFLAC, APS, or the Long Term Care Ombudsman as required by State law. The CSL, Employee #130, was interviewed at 1:36 p.m. on 10/01/13. The CSL confirmed this allegation was not reported to OHFLAC, APS or the Ombudsman. She did not know why this allegation was not reported. Employee #5, the person in charge (Administrator), was interviewed at 2:12 p.m. on 10/01/13. He stated the following in regards to this allegation, This was one which should have been reported, but was not. 5) Resident #80 The facility Concern Forms for the previous three (3) months were reviewed at 9:38 a.m. on 10/01/13. On 09/18/13 a Concern Form was completed for Resident #80. The concern was (typed as written), Resident was documented as being found wet from head to toe. There was no evidence this allegation was reported to OHFLAC, APS, or the Long Term Care Ombudsman as required. The CSL, Employee #130, was interviewed at 1:36 p.m. on 10/01/13. The CSL confirmed this allegation was not reported to OHFLAC, APS or the Ombudsman. She did not know why this allegation was not reported. Employee #5, the person in charge (Administrator), was interviewed at 2:12 p.m. on 10/01/13. He stated the following in regards to this allegation, This was another one which should have been reported, but was not. b) On 10/29/13, at approximately 11:00 a.m. the Director of Nursing provided documentation which indicated all of these incidents had been reported to the appropriate State agencies on 10/01/13. She stated the CSL reported these concern following the interview with the surveyor on 10/01/13.",2016-10-01
8078,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-10-29,441,E,1,0,L81Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure an effective infection control program to prevent the spread of infections for five (5) of six (6) residents reviewed relative to infection control. The facility failed to report all carbapenem resistant [MEDICATION NAME] (CRE) infections to the local and State health department in accordance with their policy and State requirements, failed to ensure staff were aware of resident infections and had knowledge of the infectious disease process, failed to log correct infections on the infection surveillance log, and failed to provide required protective equipment in isolation carts. Facility census: 136. Resident identifiers: #38, #21, #49, #66, #24. Findings include: The facility was entered on 09/30/13 at 9:30 a.m. During tour of the facility, four (4) isolation carts were observed outside resident rooms. On 09/30/13 and 10/01/13, the following issues were identified relative to infection control. a) Resident #21 Review of Resident #21 ' s medical record found a [DIAGNOSES REDACTED]. An interview was conducted with Employee #70, a registered nurse (RN), on 09/30/13, at 11:10 a.m. When asked whether he was sometimes in charge of the A Wing, Employee #70 stated, Yes. When asked what his response would be if a nursing assistant asked him if Resident #21 could come out of the room, he stated, I don't remember that's a pretty new disease. When asked if he was in-serviced on CRE he stated, They gave us a paper, but I don't remember, I need to refresh my memory. Observation of the isolation cart for Resident #21 found it did not have gloves stocked inside the cart. This was confirmed with Employee #45 (RN) at 3:15 p.m. on 09/30/13. Employee #77, the director of nursing (DON), was informed of this finding on 09/30/13 at 3:30 p.m. b) Resident #38 Review of the monthly orders for Resident #38 did not find a physician's orders [REDACTED]. This was confirmed by Employee #24 (medical record director), on 09/30/13 at 12:58 p.m She stated, He's been out to the hospital, maybe they just left it (the order) off. Further review of the medical record for Resident #38, on 09/30/13 at 2:40 p.m., found the facility had Resident #38 on isolation for acinetobacter. The isolation precautions had started on 07/06/13. Review of the laboratory results for Resident #38 found he did not have acinetobacter, he had citrobacter freundii and pseudomonas aeruginosa in his urine. (Acinetobacter is an epidemiologically important pathogen.) On 09/30/13 at 3:06 p.m., Resident #38 ' s isolation cart was found to not be stocked with the appropriate protective equipment. There were no gowns in the isolation cart. This finding was confirmed with Employee #151, a licensed practical nurse (LPN), at 3:06 p.m. on 09/30/13. The infection surveillance log for July 2013, provided by the facility, indicated Resident #38 had Other. When Employee #28, the assistant director of nursing (ADON)/infection control nurse) was asked what Other was, she stated, He has acinetobacter, the infection control log does not have this disease listed, so I have to put other, but he has acinetobacter. The DON, on 09/30/13 at 3:10 p.m., confirmed the facility did not have a copy of the wound culture which stated Resident #38 had acinetobacter. She further added she felt that was a mistake by the infection control nurse, that she must have read the culture wrong. The ADON-infection control nurse, on 10/01/13 at 8:50 a.m. stated the monthly infection control logs does not provide a result/organism option to add CRE or acinetobacter. She further added we have a new log, but it doesn't have an option to add these infections either. Employee #28 (ADON-infection control nurse) was asked which wound does Resident #38 have acinetobacter in? She stated, I don't know probably the one with the wound vac. Review of lab reports for this Resident #38 identified he did not have acinetobacter, and the infection control surveillance log listed him as having other. Additional medical record review for Resident #38 was completed on 10/01/13 at 9:45 a.m. It was identified Resident #38 was on contact isolation for CRE. Further review of the laboratory reports identified this resident did not have CRE, he had citrobacter freundii and pseudomonas aeruginosa in his urine. According to he DON, when informed, on 10/01/13 at 10:45 a.m., that the isolation care for this resident did not contain gloves, she commented that was not an acceptable practice. The facility ' s infection control manual, Chapter 2, Section 2, included isolation carts were to be stocked with the appropriate supplies. On 10/01/13 at 1:33 p.m., the DON stated I could not find why Resident #38 is on isolation, it appears to me that the lab that says Citobacter, was mistaken for acinetobacter instead of Citobacter. Employee #45 (RN) was asked on 10/01/13 at 2:14 p.m. what Resident #38 was on isolation for. She stated, Acinetobacter. She was told Resident #38 did not have a positive culture for acinetobacter, he had citrobacter freundii and pseudomonas aeruginosa in his urine. Employee #45 stated, That is what he was on alert charting, I did not know. Employee #201 (RN), on 10/01/13 at 2:26 p.m., was asked if she was the RN in charge of A wing and she replied, Yes. When asked what Resident #38 was on contact isolation for, she stated, I've not been here long enough to know. It runs in my mind, but I've only been here since July. During an interview with the DON on 10/01/13 at 2:40 p.m., she was informed of the findings for Resident #38. When told the resident did not have acinetobacter, in fact he has citrobacter freundii and pseudomonas aeruginosa, she stated, I think the infection control nurse probably just looked at the lab wrong and documented that he had acinetobacter. The DON was informed the monthly surveillance log used for infections just states he had other. She stated, Our log doesn't provide you an option to document the resident has CRE or acinetobacter, it's not provided on our surveillance log. Resident #66 Resident #66 was readmitted to the facility on [DATE] with acinetobacter in a wound. He was not listed on the monthly infection surveillance log for September 2013. The culture for Resident #66 was obtained on 09/23/13. Resident #49 Resident #49 was readmitted to the facility on [DATE]. She had a history of [REDACTED]. Resident #24 Resident #24's laboratory results confirmed a [DIAGNOSES REDACTED]. This was confirmed with the DON and the ADON/infection control nurse on 09/30/13, at 3:45 p.m. b) Infection Control Surveillance Log review Review of the facility's infection control surveillance log, on 09/30/13 at 3:45 p.m. found no residents were listed as having CRE or acinetobacter. Resident #66 was readmitted to the facility on [DATE], with acinetobacter in a wound, but he was not listed on the monthly infection surveillance log for September 2013. The culture for Resident #66 was obtained on 09/23/13. Further review of the infection control surveillance log found Resident #38 was listed as having other. No specific organism was identified on the surveillance log to enable tracking of the specific organism. Resident #21 was not listed on the July monthly surveillance log, although he was also on contact isolation for CRE. Resident #49 was readmitted to the facility on [DATE]. She had a history of [REDACTED]. Resident #49 was also on strict contact isolation. This resident was found to be positive for CRE on 05/02/13. According to the DON, this resident went home on 07/04/13, and then returned to the facility on [DATE]. She further stated when someone comes back in we are supposed to obtain another culture. On 10/01/13 at 3:50 p.m., the DON confirmed the facility failed to obtain a culture. On 09/30/13, at 1:45 p.m., the DON stated, We follow CDC guidelines for our infection control. c) Review of the facility ' s infection control manual The facility's infection control manual chapter seven (7) section five (5) states for multi-drug resistant outbreaks that the facility be in consultation with the local health department officials. Further review of the facility's infection control policy, on 10/01/13 at 10:15 a.m.,. found Section 2 directed that the facility was to identify, document and investigate healthcare associated infections and communicable diseases, define procedures to inform and involve local or state epidemiologist, as required by the state, collect analyze and provide infection control data and trends to nursing staff and health care practitioners. d) Interview with the health department During a telephone interview with the health department's regional epidemiologist, along with the ADON/infection control nurse, on 10/01/13 at 8:58 a.m., the epidemiologist was asked when the last time she was in the facility to investigate any issues related to CRE. She stated, It was on the letter I gave the facility which was 04/18/13. When asked how the facility was to notify the health department of CRE infections, she stated, They are supposed to use a line listing and send it to me, or they can call me. When asked when she received the last line listing from the facility, she stated, I have never received a line listing from this facility. The epidemiologist was asked whether she was aware of any new cases of CRE since 04/18/13, she stated, No, I don't have a list from them of the total cases they have, probably since 04/18/13. She further added, The facility is supposed to notify us of any laboratory results, this is required and will go to the State Health Department.",2016-10-01
8400,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-06-25,280,D,1,0,K4JI11,"Based on review of care plans and staff interview, it was found the care plan for resident #70 had not been reviewed or revised concerning intravenous (IV) therapy and peripherally inserted central catheter (PICC) line treatment. The current care plan had problems, goals, and interventions listed for these issues when the resident did not receive either of these services. This was evident for one (1) of six (6) residents in the complaint sample whose care plans were reviewed. Resident identifier: #70. Census: 132. Findings include: a) Resident #70 On 06/25/13, review of this resident's current care plan (dated 06/07/13 and effective until 09/2013) revealed a problem of Potential for complications at IV site insertion, PICC line inserted to rt. arm. According to an interview with Employee #24, a registered nurse (RN) at 4:15 p.m on 06/25/13 the resident did not have an IV or PICC line inserted. She then checked with another employee and returned shortly stating the other employee was the one who had listed the problem on the care plan and it had been in error. It should have been on another resident's care plan. Additionally IV therapy was listed in conjunction with the resident refusing treatment/care and being non-compliant with IV therapy. This did not apply either as it was identified the resident was not receiving IV therapy. Employee #24 verified this should not have been on the care plan and would be removed. The care plan was not revised as needed during the June care planning session.",2016-06-01
8401,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-06-25,309,D,1,0,K4JI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that physician orders [REDACTED]. The facility failed to ensure the dressing was changed every forty-eight (48) hours and as needed nine (9) times during the month of April 2013. Resident identifier: #133. Facility census: 132. Findings include: a) Resident #133 During a medical record review of this resident's closed medical record, on 06/24/13 at 2:00 p.m., the Medication Administration Record [REDACTED]. This dressing was to be completed on the 7 a.m. to 7 p.m. shift. The dressing was not performed on these days in April 2013 as ordered: April 5, 7, 9, 11, 13, 15, 19, 21, and 25. An interview was conducted with Employee #24, a registered nurse who was the assistant director of nursing, at 2:30 p.m. on 06/24/13, regarding the central line dressing change for Resident #133. She stated the nurse that was working the hall the days the dressing was not changed was a licensed practical nurse (LPN) and the LPN had failed to get a registered nurse to change the dressing as required. She stated the nurse who failed to ensure the dressing changes were provided did receive an educational write up.",2016-06-01
8522,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-05-30,156,D,1,0,6GZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide information upon admission to a resident to ensure the resident had knowledge of his/her rights, and information related to the responsibilities of the facility. During a random review of the medical record for Resident #67, it was discovered the resident was admitted to the facility on [DATE], but did not receive or sign information in the admission packet until ten (10) days after her admission to the facility. Resident identifiers: #67. Facility census: 137. Findings include: a) Resident #67 During a review of the medical record for Resident #67, on 05/29/13 at 12:45 p.m., it was discovered the resident was admitted to the facility on [DATE]. Further review identified the resident did not receive information provided in the facility's admission packet until 05/24/13 - two (2) weeks after admission. The facility's admission packet included the following information provided to each resident upon admission to the facility. I. Rights and Responsibilities of the patient. 1.01 Room and Board Rate 1.02 Ancillary Charges 1.02 a. Transportation 1.03 Collection/Late payments 1.04 Independent Providers 1.05 Governmental Programs 1.06 Third party payors and managed care organizations 1.07 Private pay patient 1.08 Admission information 1.09 Application for Benefits 1.10 Primary Reasonability for Payment 1.11 Personal Physician 1.12 Pharmacy II. Rights and Responsibility of the Responsible party. 2.01 Legal Authority 2.02 Agreement to make payments on behalf of patient 2.03 Exhaustion of Patient's Funds 2.04 Cooperation for Financial Assistance 2.05 Actions Upon Discharge 2.06 Additional Responsibilities III. Rights and Responsibility of the Center 3.01 Room and Standard Services 3.02 Other services 3.30 Deposit 3.04 Refunds IV. General Provisions 4.01 Consent to Release Information 4.02 Consent to Treat (signed on 05/10/13) 4.03 Consent to Photographs 4.04 Notice of Services, Polices and Additional Information 4.05 Assignment of Benefits 4.06 Termination, Discharge and Transfer 4.07 Indemnification 4.08 Venue Notice 4.09 Changes in the Law On 05/29/13, at 12:01 p.m., Employee #166 (Admissions director) stated, The admission paper work was not completed until May 24th. Employee #166 was then asked if this was standard procedure. She stated, No, we have had meetings to get admission paper work completed in a timely manner, I was not here and no one completed the paper work.",2016-05-01
8523,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-05-30,253,D,1,0,6GZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, policy review, and record review, the facility failed to prepare a clean and sanitary isolation room for one (1) of six (6) residents reviewed for infection control during the complaint investigation. Resident #67 was placed in an isolation room that was not cleaned after the last occupant was discharged and prior to her occupancy. Resident identifier: #67. Facility census: 137. Findings include: a) Resident #67 During a review of the resident's medical record, on 05/28/13 at 1:50 p.m., it was identified Resident #67 was admitted to the facility on [DATE], after 9:00 p.m. According to Employee #73 (director of nursing - DON), on 05/28/13 at 1:15 p.m., when the hospital called to give report to the nurse, the nurse was told this resident had [DIAGNOSES REDACTED] Enterococcus (VRE) in her urine. Employee #73 further stated, the resident was placed in an isolation room for contact isolation. Prior to Resident #67, being admitted to room ASC, Resident #137 was in the room. Review of the facility's Monthly infection surveillance log, on 05/28/13 at 12:45 p.m., identified Resident #137 had a [DIAGNOSES REDACTED]. On 05/10/13, Resident #137 was moved to a different room at 9:00 p.m. According to the nursing note found in the medical record, Resident #67 was admitted to the same room (ASC) on 05/10/13 at 10:22 p.m. On 05/29/13 at 8:26 a.m., interview with Employee #45 (registered nurse-RN) identified she came in for her shift at 10:30 p.m. She stated, I can't remember if Resident #67 was in the room or in route. I did not see anyone or hear anyone say they cleaned that room. I have not been trained to clean an isolation room when a resident is discharged . Resident #137 was already in the new room. I assisted the nurses with Resident #67's admission paper work. 05/29/13 at 09:29 a.m., in an interview with Employee #46 (licensed practical nurse-LPN), she stated, I don't know who cleaned the room. I know the nurses thought she had VRE. The nursing supervisor, Employee #190 made the decisions. She called Employee #25 (ADON), because she was the nurse on call. The aide (Employee #20), come down the hall to let me know she moved Resident #137. Employee #20 said she moved Resident #137 and his stuff. Employee #190 (evening shift supervisor), ordered the move for Resident #67 to move in Resident #137's old room. I don't know anything else, I was on my med-pass and the supervisors took care of the move and the admission. 05/29/13 at 10:50 a.m., in an interview with Employee #25 (assistant director of nursing - ADON - who was the nurse on call on 05/10/13), she stated, I had to be the nurse on call. Yes it was me. I don't remember the nurses calling me about Resident #67, they said they did, but I don't remember, I get so many calls. Employee #190 (registered nurse - RN- evening shift supervisor) could not be interviewed. Employee #73 (DON) stated, she was in the hospital. In a confidential interview held on 05/29/13, an employee state I did not see anybody clean it, I did not move her in the room and did not move him out. I don't know anything else. A confidential interview held on 05/29/13, revealed, I was Resident #67's aide for an hour on the 10th. I moved Resident #137 and his things to room G1A. Bed 2 in ASC was already clean, which was the bed they wanted to move Resident #67 in. Employee #190 (RN- evening shift supervisor refused to clean the room. We did not have a housekeeper that night. Employee #137 (housekeeper) was supposed to be here, but he called in. The other housekeeper was off that night. We told Employee #190 (RN-evening shift supervisor), the room was not clean. Employee #190 said move her to bed 2 and the housekeeper can clean the room tomorrow. I swept the floor. Resident #137 got moved to a clean room. No other cleaning was done. She (Employee #190) told Employee #70 (nurse aide) you have to move her. Another confidential interview held on 05/29/13 revealed I remember that night. I moved her (Resident #67) in that room (ASC) in bed B. The nurse was Employee #190 (evening shift supervisor), she told me to move her (Resident #67). I questioned it because Resident #137 was in bed A with an infection, that same night 10 minutes later I was moving Resident #67 in bed B. I questioned it because the room had not been cleaned. Employee #190 (RN-evening shift supervisor) said the housekeepers will get it in the morning. On 05/29/13 at 8:48 a.m., Employee #142 (housekeeping/laundry supervisor) provided a copy of the facility's Housekeeping Manual Standards & Procedures. The policy states, Housekeeping staff will clean and disinfect an isolation room in a manner as to protect the housekeeping and all staff from contamination and prevent the spread of disease. During a review of the facility's housekeeping schedule, on 05/28/13 at 12:50 p.m., it was identified Employee #137 (housekeeper) had been scheduled to work the evening shift on 05/10/13. During an interview with Employee #142 (housekeeping/laundry supervisor) on 05/28/13 at 2:45 p.m., it was identified Employee #137 had called in on the evening of 05/10/13. Employee #142 (housekeeping/laundry supervisor) confirmed, on 05/29/13 at 2:15 p.m., Employee #137 did not come to work on 05/10/13. On 05/29/13 at 2:35 p.m., Employee #73 stated, She could not provide any evidence the room, A Special Care (ASC), was cleaned prior to Resident #67 occupying the room.",2016-05-01
8524,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-05-30,441,D,1,0,6GZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and record review, the facility failed to maintain an infection control program to prevent the spread of disease and infection and failed to track all residents on the monthly surveillance log. This affected two (2) of six (6) residents reviewed for infection control. Resident #67 was placed in an isolation room that was not cleaned prior to her occupancy and Resident #55 was not placed on the monthly surveillance log. Facility census: 137. Resident identifiers: #67 and #55. Findings include: a) Resident #67 During a review of the resident's medical record, it was identified Resident #67 was admitted to the facility on [DATE] after 9:00 p.m. According to Employee #73 (director of nursing - DON) on 05/28/13 at 1:15 p.m., when the hospital called to give report to the nurse, they were told this resident had [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) in her urine. Employee #73 further stated the resident was placed in an isolation room for contact isolation. On 05/11/13, the facility contacted the hospital to clarify whether or not the resident had active VRE. When the facility found out it was only a history of VRE, on 05/11/13, the resident was moved out of the isolation into another room. The hospital records, sent with the resident on 05/10/13, at the time of her admission, stated the resident had a history of [REDACTED]. On 05/29/13 at 9:45 a.m., Employee #73 (DON) was asked if the nurses review the information from the hospital. She stated, Yes, they are supposed to. When shown the admission information sent from the hospital where it was written the resident only had a history of [REDACTED]. Prior to Resident #67, being admitted to room A Special Care (ASC), Resident #137 had resided in the room. Review of the facility's Monthly infection surveillance log, on 05/28/13 at 12:45 p.m., identified Resident #137 had a [DIAGNOSES REDACTED]. Review of Resident #137's medical record, on 05/29/13 at 1:30 p.m., identified Resident #137 had been moved from ASC to another room at 9:00 p.m. on 05/10/13. On 05/08/13 at 4:33 p.m., the facility had received the lab results reporting the resident was negative for[DIAGNOSES REDACTED]. The resident was not moved from the isolation room at that time. He was not moved until 05/10/13, when Resident #67 arrived at the facility. According to the nursing note found in the medical record, Resident #67 was admitted to the same room (ASC) on 05/10/13 at 10:22 p.m. Interviews were conducted with staff related to cleaning of the room prior to Resident #67 taking occupancy. 05/29/13 at 8:26 a.m., Employee #45 (registered nurse-RN) identified she had come in for her shift at 10:30 p.m. She stated, I can't remember if Resident #67 was in the room or in route. I did not see anyone or hear anyone say they cleaned that room. I have not been trained to clean an isolation room when a resident is discharged . Resident #137 was already in the new room. I assisted the nurses with Resident #67's admission paper work. 05/29/13 at 09:29 a.m., Employee #46 (licensed practical nurse-LPN) stated, I don't know who cleaned the room. I know the nurses thought she had VRE. The nursing supervisor, Employee #190 made the decisions. She called Employee #25 (ADON), because she was the nurse on call. The aide (Employee #20), come down the hall to let me know she moved Resident #137. Employee #20 said she moved Resident #137 and his stuff. Employee #190 (evening shift supervisor), ordered the move for Resident #67 to move in Resident #137's old room. I don't know anything else, I was on my med-pass and the supervisors took care of the move and the admission. 05/29/13 at 10:50 a.m., Employee #25, the assistant director of nursing (ADON) who had been the nurse on call on 05/10/13, stated, I had to be the nurse on call. Yes it was me. I don't remember the nurses calling me about Resident #67, they said they did, but I don't remember, I get so many calls. Employee #190 (RN- evening shift supervisor) could not be interviewed. Employee #73 (DON) stated, she was in the hospital. Confidential interview, held on 05/29/13, I did not see anybody clean it, I did not move her in the room and did not move him out. I don't know anything else. Confidential interview held on 05/29/13, I was Resident #67's aide for an hour on the 10th. I moved Resident #137 and his things to room G1A. Bed 2 in ASC was already clean, which was the bed they wanted to move Resident #67 in. Employee #190 (RN- evening shift supervisor) refused to clean the room. We did not have a housekeeper that night. Employee #137 (housekeeper) was supposed to be here, but he called in. The other housekeeper was off that night. We told Employee #190 (RN-evening shift supervisor), the room was not clean. Employee #190 said move her to bed 2 and the housekeeper can clean the room tomorrow. I swept the floor. Resident #137 got moved to a clean room. No other cleaning was done. She (Employee #190) told Employee #70 (nurse aide) you have to move her. Confidential interview held on 05/29/13, I remember that night. I moved her (Resident #67) in that room (ASC) in bed B. The nurse was Employee #190 (evening shift supervisor), she told me to move her (Resident #67). I questioned it because Resident #137 was in bed A with an infection, that same night 10 minutes later I was moving Resident #67 in bed B. I questioned it because the room had not been cleaned. Employee #190 (RN-evening shift supervisor) said the housekeepers will get it in the morning. On 05/29/13 at 8:48 a.m., Employee #142 (housekeeping/laundry supervisor) provided a copy of the facility's Housekeeping Manual Standards & Procedures). The policy states, Housekeeping staff will clean and disinfect an isolation room in a manner as to protect the housekeeping and all staff from contamination and prevent the spread of disease. During a review of the facility's housekeeping schedule on 05/28/13, at 12:50 p.m., identified Employee #137 (housekeeper) was scheduled to work the evening shift on 05/10/13, during an interview with Employee #142 (housekeeping/laundry supervisor) on 05/28/13 at 2:45 p.m., it was identified Employee #137, called in on the evening of 05/10/13. On 05/29/13, at 2:35 p.m., Employee #73 stated, She could not provide any evidence room ASC was cleaned prior to Resident #67 occupying the room. (Clostridium difficile is a virus which produces spores that can survive in the environment unless the appropriate cleaning procedures are employed.) ==== b) Resident #55 During a tour of the facility, on 05/28/13, at 10:45 a.m., an isolation cart and signage were observed posted outside the room of Resident #55. Review of the medical record for this resident confirmed she had tested positive for Carbapenem resistant [MEDICATION NAME] (CRE) on 05/05/13. Further review of the medical record revealed a physician's orders [REDACTED]. Contact isolation. On 05/28/13 at 12:55 p.m., the monthly infection surveillance log was reviewed. Resident #55 was not listed on the monthly surveillance log, although it had been over three (3) weeks since the resident had tested positive for CRE. Review of the facility's, Infection control surveillance policy, states on page eight (8), If cultures are taken, the patient's name and pertinent information is entered on the log. During an interview with Employee #73 (DON), on 05/29/13 at 2:15 p.m.,, it was identified Resident #55 should have been on the monthly infection surveillance log, but was not.",2016-05-01
8525,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-05-30,465,D,1,0,6GZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, policy review, and record review, the facility failed to maintain a safe and sanitary environment for a resident. This practice affected one (1) of ten (10) sampled resident during the complaint investigation. Resident #67 was placed in an isolation room which had not been cleaned prior to her admission. Resident identifier: #67. Facility census: 137. Findings include: a) Resident #67 During a review of the medical record it was identified Resident #67 was admitted to the facility on [DATE], after 9:00 p.m. According to Employee #73 (director of nursing - DON) on 05/28/13 at 1:15 p.m., when the hospital called to give report to the nurse they were told this resident had [MEDICATION NAME] resistant [MEDICATION NAME] (VRE) in her urine. Employee #73 further stated, the resident was placed in an isolation room for contact isolation. On 05/11/13, the facility contacted the hospital to clarify whether or not the resident had active VRE. When the facility found out it was only a history of VRE on 05/11/13, the resident was then moved out of isolation into another room. Review of the hospital records sent went the resident on 05/10/13, at the time of her admission stated the resident had a history of [REDACTED].#73 (DON) was asked if the nurses review the information from the hospital. She stated, Yes, they are supposed to. I then showed her in the admission information sent from the hospital it was written the resident only had a history of [REDACTED].#73 (DON) stated, The hospital stated when they called the report the resident had active VRE, so we prepared an isolation room. Prior to Resident #67, being admitted to room ASC, Resident #137 was in the room. Review of the facility's Monthly infection surveillance log, on 05/28/13, at 12:45 p.m., identified Resident #137 had a [DIAGNOSES REDACTED]. On 05/10/13, Resident #137 was moved to a different room, at 9:00 p.m. He was moved to room G1A. On 05/08/13 at 4:33 p.m., the facility had received the lab results reporting the resident was negative for [MEDICAL CONDITION] on 05/08/13. The resident was not moved from the isolation room at that time. He was not moved until 05/10/13, when Resident #67 arrived at the facility. According to the nursing note found in the medical record, Resident #67 was admitted to the same room (ASC) on 05/10/13 at 10:22 p.m. Further review of the medical record, on 05/29/13 at 1:30 p.m., identified Resident #137 was moved to another room at 9:00 p.m. Interviews were conducted with staff related to cleaning of the room prior to Resident #67 taking occupancy. 05/29/13 at 8:26 a.m., Interview with Employee #45 (registered nurse-RN) identified she came in for her shift at 10:30 p.m. She stated, I can't remember if Resident #67 was in the room or in route. I did not see anyone or hear anyone say they cleaned that room. I have not been trained to clean an isolation room when a resident is discharged . Resident #137 was already in the new room. I assisted the nurses with Resident #67's admission paper work. 05/29/13 at 09:29 a.m. - interview with Employee #46 (licensed practical nurse-LPN). she stated, I don't know who cleaned the room. I know the nurses thought she had VRE. The nursing supervisor Employee #190 made the decisions. She called Employee #25 (ADON), because she was the nurse on call. The aide (Employee #20), come down the hall to let me know she moved Resident #137. Employee #20 said she moved Resident #137 and his stuff. Employee #190 (evening shift supervisor), ordered the move for Resident #67 to move in Resident #137's old room. I don't know anything else, I was on my med-pass and the supervisors took care of the move and the admission. 05/29/13 at 10:50 a.m., Interview with Employee #25 (ADON - the nurse on call on 05/10/13.) Stated, I had to be the nurse on call. Yes it was me. I don't remember the nurses calling me about Resident #67, they said they did, but I don't remember, I get so many calls. Employee #190 (RN- evening shift supervisor) could not be interviewed. Employee #73 (DON) stated, she was in the hospital. Confidential interview held on 05/29/13, I did not see anybody clean it, I did not move her in the room and did not move him out. I don't know anything else. Confidential interview held on 05/29/13, I was Resident #67's aide for an hour on the 10th. I moved Resident #137 and his things to room G1A. Bed 2 in ASC was already clean, which was the bed they wanted to move Resident #67 in. Employee #190 (RN- evening shift supervisor refused to clean the room. We did not have a housekeeper that night. Employee #137 (housekeeper) was supposed to be here, but he called in. The other housekeeper was off that night. We told Employee #190 (RN-evening shift supervisor), the room was not clean. Employee #190 said move her to bed 2 and the housekeeper can clean the room tomorrow. I swept the floor. Resident #137 got moved to a clean room. No other cleaning was done. She (Employee #190) told Employee #70 (nurse aide) you have to move her. Confidential interview held on 05/29/13, I remember that night.: I moved her (Resident #67 ) in that room (ASC) in bed B. The nurse was Employee #190 (evening shift supervisor), she told me to move her (Resident #67). I questioned it because Resident #137 was in bed A with an infection, that same night 10 minutes later I was moving Resident #67 in bed B. I questioned it because the room had not been cleaned. Employee #190 (RN-evening shift supervisor) said the housekeepers will get it in the morning. On 05/29/13 at 8:48 a.m., Employee #142 (housekeeping/laundry supervisor) provided a copy of the facility's Housekeeping Manual Standards & Procedures). The policy states, Housekeeping staff will clean and disinfect an isolation room in a manner as to protect the housekeeping and all staff from contamination and prevent the spread of disease. A review of the facility's housekeeping schedule on 05/28/13 at 12:50 p.m., identified Employee #137 (housekeeper) was scheduled to work the evening shift on 05/10/13. During an interview with Employee #142 (housekeeping/laundry supervisor) on 05/28/13 at 2:45 p.m., it was identified Employee #137, called in on the evening of 05/10/13. On 05/29/13, at 2:35 p.m., Employee #73 stated, She could not provide any evidence room ASC was cleaned prior to Resident #67 occupying the room.",2016-05-01
8526,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-05-30,502,D,1,0,6GZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain two (2) labs as ordered by a physician. One resident's physician ordered a lab test for [MEDICAL CONDITION] (which causes severe diarrhea), but the test was not completed, and a lab test for urinary tract infection was not collected in a timely manner. This practice affected one (1) of six (6) residents whose medical records were reviewed. Resident identifier: #37. Facility census: 136. a) Resident #37 Review of this resident's medical record, on 05/28/13 at 2:57 p.m., revealed on 04/11/13 the physician ordered a stool culture and [MEDICAL CONDITION] test to be collected due to [DIAGNOSES REDACTED].Review of the physician's orders [REDACTED]. Review on the nurses' progress notes, on 05/28/13 at 3:05 p.m., found no evidence the physician was notified the lab tests had not been obtained. The facility's lab tracking sheet was reviewed on 05/28/13 at 3:15 p.m. This revealed the lab test had been placed on the lab tracking document on 04/12/13, but was marked out and noted Did Not Obtain. In an interview with Employee #222, a registered nurse (RN), on 05/28/13 at 3:37 p.m., she was asked where Resident #37's lab results were for the stool culture and [MEDICAL CONDITION] which were ordered on [DATE]. After reviewing the lab tracking worksheet, she confirmed the tests were not collected. She stated she did not know why the tests were not collected. In an interview with Employee #73, the director of nursing (DON), on 05/28/13 at 3:10 p.m., she stated she would have to look at Resident #37's chart. At 3:15 p.m., the DON confirmed staff did not do the test, nor did staff notify the physician the lab tests were not obtained. b) Resident #37 Review of the resident's medical record, on 05/28/13 at 3:30 p.m., found the physician had ordered a urinalysis and urine culture for dysuria (painful urination) on Thursday, 04/18/13 at 10:30 p.m. Further review of the record revealed the urinalysis and urine culture were not obtained until on Sunday, 04/21/13 at 11:55 a.m. Review of the toileting documentation sheet for bladder on, 05/28/13 at 3:35 p.m., revealed Resident #37 had voided multiple times prior to the time the urinalysis and urine culture were obtained on 04/21/13. Employee #222, a registered nurse (RN) was interviewed on 05/28/13 at 3:37 p.m. When asked why the urine specimen for the tests was not obtained in a timely manner, she confirmed the staff should have obtained sooner.In an interview on 05/30/13 at 10:05 a.m., with Employee #73, the director of nursing (DON), she did not know why staff did not collect the lab test in a timely manner.",2016-05-01
8848,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-03-19,272,D,1,0,VGZX11,"Based on medical record review and staff interview, the facility failed to conduct a comprehensive assessment that accurately reflected each residents' health condition. This was found for one (1) of six (6) sample residents. Resident identifier: #73. Facility census: 124. Findings include: a) Resident #73 Review of the resident's medical record, on 03/18/13 at 3:55 p.m., found the minimum data set (MDS) assessment, with an assessment reference (ARD) date of 01/12/13, indicated the resident did not have any pressure ulcers. An SBAR (a communication tool used when there is a change in the resident's condition) note, dated 01/11/13 at 1700 (5:00 p.m.), noted the resident had an area to the left heel that was pressure and friction related. A note by the MDS nurse, dated 01/14/13 at 15:34 (3:34 p.m.), included a statement the fluid filled blister was noted, but was not pressure related. Another note, dated 01/16/13 at 15:34, stated the left heel was a pressure area. The resident's care plan, created on 01/11/13, noted the area to the left heel was pressure related. On 01/22/13, a 14 day Medicare MDS was started and it did not include the pressure ulcer. The Director of Nursing (Employee #72) was interviewed, on 03/18/13 at 4:35 p.m., regarding the coding of the resident's pressure ulcer on the MDS and the documentation. She stated the MDS, with an ARD of 01/12/13, should have been coded to include the pressure ulcer since staff had been documenting it as a pressure area since 01/11/13.",2016-03-01
8849,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-03-19,279,D,1,0,VGZX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a care plan based on the resident ' s comprehensive assessment. The care plan included a plan for pressure ulcers which the resident was not assessed as having. One (1) of six (6) sample residents was affected. Resident identifier: #126. Facility census: 124. Findings include: a) Resident #126 Medical record review, on 03/19/13 at 8:50 a.m., found Resident #126 was admitted to the facility on [DATE] and discharged on [DATE]. Resident #126 had a quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/12/13, which was coded to indicate the resident had no pressure ulcers. The resident ' s care plan, developed 11/14/12, identified the resident as having skin breakdown to his left great toe. There was no resolution date by which the skin breakdown was to be healed. In an interview, on 03/19/13 at 10:30 a.m., Employee #72, the Director of Nursing, stated the facility had identified they had a problem with wound documentation and had taken this issue to the QA committee. She stated the committee started their improvement process in November 2012. She said this documentation should have been picked up by the QA committee. The Director of Nursing stated that she had looked through the resident's medical record and could not find any documentation regarding a wound. Other than what was on the care plan, there was nothing to indicate the resident had ever had any skin breakdown. She stated she wondered if the care plan could have been on the wrong resident.",2016-03-01
8850,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-03-19,441,D,1,0,VGZX11,"Based on observations, policy review, staff interview, and resident interview, the facility failed to maintain a safe and sanitary environment. The facility failed to ensure nebulizer equipment was cleaned and stored in a manner to prevent the spread of infectious organisms. This practice affected two (2) of six (6) sample residents and had the potential to affect all residents who received nebulizer treatments. Resident identifiers: #45 and #73. Facility census: 124. Findings include: a) Resident #45 During the initial tour, on 03/18/13 at 10:15 a.m., Resident #45's nebulizer mask was noted to be on the resident and running while the resident was sleeping, but no mist was noted to be coming from the mask. Employee #197, a Registered Nurse (RN), was asked how long this machine had been running and she stated she did not know, but would ask. The RN returned and stated ten (10) minutes and removed the nebulizer mask and placed it in a plastic bag. When the RN was asked if the nebulizer would be rinsed she stated that she would not - that the other nurse taking care of this resident would. On 03/18/13 at 10:40 a.m., Employee #218, the Administrator, was asked about the care of the nebulizer and who was to clean the nebulizer tubing. She stated the nurse who removed the mask should clean it. Review of the facility's policy on nebulizer mist therapy, on 03/18/13 at 12:00 p.m., found the procedure included in Step #18 Rinse excess mist and medication from nebulizer, t-piece, mouthpiece or mask. Step #19 instructed Store dried nebulizer, t-piece, mouthpiece, or mask in separate labeled plastic bag. By putting the nebulizer in the plastic bag without having rinsed it to make sure it was free of excess mist/medication, as well as any mucus and saliva, the unclean mask was stored it what was supposed to be a clean bag. b) Resident #73 Observation of Resident #73, on 03/18/13 at 3:10 p.m., noted the resident's nebulizer was on the chair in her room. The mouthpiece was not in a plastic bag. On 03/18/13 at 3:10 p.m., when Resident #73 was asked what the nurse did with the nebulizer when she was finished with her treatment, stated It lays right there and sometimes it falls on the floor and they pick it up and put it back on the chair. On 03/18/13 at 3:15 p.m., Employee #2, a Licensed Practical Nurse, was asked about the care of a nebulizer after a resident finished a treatment. She stated she takes it, cleans it out, and places it in the plastic bag. This nurse observed the nebulizer of Resident #73 laying on the chair and removed it and placed it in the garbage. In an interview, on 03/18/13 at 3:45 p.m., Employee #72, the Director of Nursing, stated all employees that were in the facility on this day had been re-educated on the care of the nebulizers and stated she would educate the nurse who had left the nebulizer on the chair again.",2016-03-01
9194,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-01-10,225,D,1,0,UD9011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, review of the facility's reported allegations and associated investigations, and record review, the facility failed to immediately report an allegation of abuse to the appropriate authorities for one (1) of eight (8) sample residents. Resident #148 was identified as sustaining a second fracture to his left arm/shoulder on 12/17/12. The facility reported the incident to the Office of Health Facility Licensure and Certification (OHFLAC) as an injury of unknown origin. During the investigation it was found the resident had reported an allegation of abuse to two (2) employees who failed to immediately report the incident to the administrator. Also, the facility failed to thoroughly investigate all staff members working with the resident on the day of the incident, and failed to submit the five (5) day investigation report in a timely manner. Resident #148. Facility census: 147. Findings include: a) Resident #148 The nursing progress notes for this resident were reviewed on 01/08/13 at 2:15 p.m. The notes, dated 12/17/12, described the resident was complaining of pain in the left shoulder. According to the notes, Upon assessment, left shoulder noted to have swelling, little active range of motion, and possible deformity of upper arm. The physician was notified and ordered an immediate x-ray at first, but then the physician ordered the resident to be sent to the emergency room for evaluation. Resident #148 went to the emergency room where he was diagnosed with [REDACTED]. He returned to the facility with orders for his arm to remain in a sling, and to discontinue physical therapy (PT) until the attending physician gave approval to restart PT. The resident was to do no lifting, pulling, or use the left arm. During an interview with Employee #219 (administrator), on 01/09/13, it was discovered the facility immediately began an investigation after the second fracture was confirmed on 12/18/12. The facility reported the incident to OHFLAC on 12/18/12, as an injury of unknown origin. Further review of the medical record, on 01/08/13 at 2:15 p.m., found on 12/19/12, Resident #148 was found in a puddle of blood with the surgical pin protruding through the skin on his left shoulder. He was immediately sent to the emergency room for evaluation. During an interview with the administrator, on 01/09/13 at 11:15 a.m., it was discovered two (2) nursing assistants reported Resident #148 had made an allegation of abuse related to his incident. The two (2) nursing assistants, Employee #23 and Employee #95, did not immediately report the incident to the administrator. The administrator stated, I found this out during the investigation of the injury of unknown origin. The administrator further stated, the power of attorney (POA) for Resident #148 had also reported an allegation of abuse to Employee #24 (social worker) on 12/20/12. Review, on 01/09/13 at 11:30 a.m., of the statement provided by the POA to the social worker on 12/2012 found the following: I stepped out into the hallway while they were getting him ready to go to the hospital. While in the hall, I spoke with a very nice nursing assistant, I can't remember her name, but I think it was (named the nursing assistant) Employee #95. She had sort of longer hair, kind of blondish-brown. She has cared for my husband before, actually I would love for Employee #95 to be the person who takes care of my husband all the time - she is just so nice. My husband would call her mashed potatoes. Employee #95 told me that someone did this to my husband because they handled him too rough and I (Employee #95) know who this person is and I (Employee #95) reported it to the nurse. On 01/09/13 at 11:30 a.m., the administrator confirmed Employee #95 (nurse aide) and Employee #23 (nurse aide) reported the allegation of abuse to her, but failed to immediately report the allegation of abuse. During this interview, the administrator was asked why the incident was not then reported as an allegation of abuse. No response was given. At 11:51 a.m. on 01/10/13, the administrator was asked if the two (2) nursing assistants who did not immediately report the allegation of abuse were reprimanded. She stated, It wasn't addressed in written form, we don't have that yet. Review of the investigation for the injury of unknown origin, on 01/09/13 at 11:30 a.m., discovered Employee #95 named the perpetrator as Employee #17 (nurse aide). Further review found the facility did not interview Employee #17 (nurse aide) related to the incident, which occurred on 12/17/12, until 01/07/13. The administrator was asked why Employee #17 (nurse aide) was not interviewed for such a long period of time. She stated, She works PRN (as needed). Further review of the investigation, on 01/09/13 at 11:30 a.m., found Resident #148 had therapy services on 12/17/12. There was no evidence therapy staff was interviewed related to the fracture. A facility statement provided during the investigation by Employee #190 (licensed practical nurse), revealed on 12/18/12, the resident's wife (and POA) asked her if her husband had fallen. The wife stated, I was just wondering because Employee #150 (licensed practical nurse) told me she found him in the bathtub with his clothes on. During an interview with Employee #17, a nursing assistant, on 01/10/13, at 11:51 a.m., Employee #17 stated the following: He had urinated and I rolled him so I could change him. His arm didn't feel right. I felt something so I went and got the nurse. It was my first time having him I believe. He was the easiest person I had. He was uncomfortable. I had heard the nurse earlier say maybe he had fallen in the the bathtub. I heard _________ (Employee #150,a licensed practical nurse) say this to his wife. I understood he was in the bathtub and there was no [MEDICATION NAME] and he was trying to get a bath. He was already complaining of pain before I touched him. I like that little guy. Immediately following the interview with Employee #17 on 01/10/13 at 11:51 a.m., the facility suspended the employee related to her failure to report the alleged fall in the bathtub. Following the interview with Employee #17, during an interview, at 11:58 p.m., with the director of nursing (DON), she stated she was not sure the room had a a bathtub. At that time, an observation was conducted, with the DON, of the room in which Resident #148 previously resided. Observation revealed there was a bathtub in this room. There was no evidence the facility ever followed up on the incident in the bathtub. Further review of the investigation report identified the five (5) day follow up was completed on 12/27/12, but was not submitted to OHFLAC until 12/31/12. Employee #219 confirmed the follow-up report was not submitted timely, on 01/10/12 at approximately 11:55 a.m.",2016-01-01
9195,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-01-10,441,D,1,0,UD9011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain infection control precautions for two (2) of seven (7) residents. Observation of two (2) rooms of residents on isolation revealed no signage to notify staff and visitors of isolation procedures. Facility census: 147. Resident identifiers: #129 and #54. Findings include: a) Resident #54 Observation of Room #E13, on 01/08/13 at 11:30 a.m., found an isolation cart outside of the room. No signage was found to identify the resident was on isolation precautions. Review of the medical record for this resident identified she was on reverse (protective) isolation for chronic [DIAGNOSES REDACTED] (a condition characterized by abnormally low levels of a certain white blood cell that plays an essential role in fighting bacterial infections). During an interview with Employee #73 on 1/10/13, at 10:26 a.m., it was confirmed the sign should have been posted on the door. b) Resident #129 Observation of Room #B4, on 01/08/13 at 11:20 a.m., found an isolation cart outside of the room. No signage was found to identify the resident was on isolation precautions. Employee #95 was asked what the cart was for she stated, We have to wear gloves when we go in there, she's got something. Review of the medical record identified Resident #129 was on isolation related to methicillin resistant staphylococcus aureus (MRSA - an organism that is resistant to many antibiotics). During an interview with Employee #73, on 1/10/13, at 10:26 a.m., it was confirmed the sign should have been posted on the door.",2016-01-01
9546,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,154,D,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to inform one (1) of twenty-one (21) sampled residents of the potential risks and available alternative treatments relating to bladder elimination. An alert and oriented resident, whose indwelling Foley urinary catheter continued to be used at her request (beyond the time-limited physician's orders [REDACTED]. Resident identifier: 25. Facility census: 157. Findings include: a) Resident #25 Resident #25's medical record, when reviewed on 11/19/09 at 1:30 p.m., revealed a [AGE] year old female who was admitted to the facility on [DATE]. The resident was alert and oriented and had been determined by her physician to possess the capacity to understand and make informed healthcare decisions. The resident was on bedrest due to a fall at home resulting in fractures to the lumbar spine. The physician ordered an indwelling Foley urinary catheter for seven (7) days on 11/01/09 due to excoriation. Resident #25, when observed in bed at 1:45 p.m. on 11/19/09, had in place an indwelling urinary catheter. The resident, when interviewed, reported she did not want the catheter removed until she was off of bedrest and able to ambulate. The director of nurses (DON - Employee #165), when interviewed on 11/20/09 at 3:15 p.m., reported it was the resident's choice to keep the catheter. However, the DON did acknowledge the facility failed to inform the resident of potential risks of continuing to use an indwelling catheter over an extended period of time or alternative treatments available.",2015-10-01
9547,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,156,C,0,1,5V2011,"Based on observation and staff interview, the facility failed to include the name, address, and telephone number of the State long-term care ombudsman together in its posting of information. This practice had the potential to affect all residents and visitors. Facility census: 157. Findings include: a) On 11/17/09, an observation of the facility's posting in the front lobby, which included names and addresses of individuals who could be contacted for questions related to long term care, revealed the facility had not listed the name of the State long term care (LTC) ombudsman. On 11/20/09 at 4:00 p.m., the administrator agreed the State ombudsman's name needed listed and agreed to change the posting to correct the issue. (NOTE: On 12/02/09, the administrator faxed to the State survey agency a copy of a posting titled Information Services located elsewhere in the facility. While it did contain the State LTC ombudsman's name and telephone number, it did not contain an address. Consequently, an individual who wanted the name, telephone number, and mailing address of the State LTC ombudsman would have had to locate and access both postings to obtain complete contact information.)",2015-10-01
9548,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,158,C,0,1,5V2011,"Based on review of resident funds, staff interview, and the confidential resident group interview, the facility failed to assure residents had access to petty cash on an ongoing basis. This practice had the potential to affect all residents for whom the facility handled funds. At the time of the survey, the facility handled funds for one hundred-twelve (112) residents. Facility census: 157. Findings include: a) On 11/19/09 at 2:30 p.m., residents' accounts were reviewed with the office manager and the staff member who handled resident funds. At that time, it was revealed residents only had access to their personal funds during the facility's regular business hours and for four (4) hours each Saturday and Sunday. This was confirmed during the confidential resident group meeting held on 11/18/09.",2015-10-01
9549,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,176,D,0,1,5V2011,"Based on observation and medical record review, the facility failed to assure one (1) of twenty-one (21) facility residents was safe to self-administer drugs prior to allowing the resident to keep medication at the bedside. Resident identifier: #112. Facility census: 157. Findings include: a) Resident #112 During observation of the medication administration pass on 11/17/09 at 10:00 a.m., Resident #112 was overheard telling to the licensed practical nurse (LPN - Employee #195) that the night shift nurse gave her Aspercreme to keep in her room. Employee #195 reported the resident's statement. The assistant administrator (Employee #74) retrieved two (2) used tubes of Aspercreme from the resident's nightstand with her permission. Review of the medical record found the current minimum data set (MDS) with an assessment reference date (ARD) of 09/15/09. Review of this MDS found, in Section S1, the assessor determined the resident was not capable of safe self-administration of medications.",2015-10-01
9550,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,221,D,0,1,5V2011,"Based on random observation and staff interview, the facility failed to assure each resident was free from physical restraints imposed for staff convenience. Facility personnel allowed a chair alarm to become a physical restraint for one (1) resident of random opportunity. Resident identifier: #32. Facility census: 157. Findings include: a) Resident #32 On 11/17/09 at 4:25 p.m., this resident was observed seated in front of Building 2's nursing station. At 4:26 p.m., the resident began rising from the wheelchair, and an alarm sounded. Employee #7 ( a licensed practical nurse - LPN) immediately looked up and across the nursing station. She loudly said, Ah! Ah! Sit back in your chair! Employee #7 did not attempt to ascertain why the resident wanted up and did not direct anyone else to attempt to determine his needs. Directing the resident to sit down, instead of ascertaining the resident's needs when an alarm sounds, results in that alarm becoming a restraining device for that resident. This information was provided to the director of nursing (DON - Employee #165) at 4:35 p.m. on 11/17/09. At that time, the DON confirmed that staff should have asked the resident what he needed instead of telling the resident to sit back down.",2015-10-01
9551,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,224,E,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure residents received treatments as prescribed by their physicians. This was true for three (3) of twenty-one (21) sampled residents and six (6) random residents. There was no evidence these nine (9) residents received their scheduled treatments on 11/14/09 (7:00 a.m. - 7:00 p.m. shift) as prescribed by the physician. Resident identifiers: #16, #15, #24, #33, #42, #76, #78, #111, and #112. Facility census: 157. Findings include: a) Resident #16 Resident #16 was observed on 11/17/09 at 9:35 a.m. in his room. The treatment nurse (a registered nurse - Employee #122) was observed changing the dressing on his left lower leg. The existing dressing was observed to be dated 11/11/09. The treatment nurse confirmed the date on the dressing to be 11/11/09 and then removed the dressing which had been covering a skin tear. The area was observed to be scabbed over and free from any redness or drainage. The treatment nurse reviewed the November 2009 treatment sheet and reported the dressing was scheduled to be changed on 11/14/09. The treatment nurse reported the treatment was not initialed on 11/14/09, which would have indicated the treatment was completed as ordered by the physician. Resident #16's medical record, when reviewed on 11/17/09 at 10:30 a.m., confirmed the physician had ordered the following treatments: Cleanse area to (L) Shin with NSS, pat dry, apply OpSite Q3days (every three days) and PRN (as needed), Moisture Barrier to coccyx BID (twice daily), Moisture Barrier to ABD fold BID, and Check O2 SAT QS (every shift) if below 90% notify MD. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator (Employee #78), when interviewed on 11/18/09 at 4:35 p.m., stated the treatment nurse (Employee #122) reported the omission of the treatments to her, an allegation of neglect was reported to the State agencies, and the facility's investigation into this was ongoing. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #16 had been reported to the State agencies. The director of nurses (DON - Employee #165), when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. b) Resident #15 Resident #15's medical record, when reviewed on 11/17/09 at 2:10 p.m., revealed the physician had ordered the following treatments: Check SPO2 every shift and PRN notify MD if Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #15's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #15 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. c) Resident #24 Resident #24's medical record, when reviewed on 11/17/09 at 2:20 p.m., revealed the physician had ordered the following treatments: Barrier cream to peri area and buttocks BID. Skin prep to bilateral heels QS D/T (due to) redness / soft. Abdominal binder at all times as tolerated, remove for care, and float heels while in bed, may remove for care. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #24's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #24 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. d) Resident #33 Resident #33's medical record, when reviewed on 11/17/09 at 240 p.m., revealed the physician had ordered the following treatments: Check O2 SAT QS and PRN, below 90% notify MD, Greers Goo to buttocks BID, [MEDICATION NAME] cream to thigh and ABD fold BID. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #33's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #33 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. e) Resident #42 Resident #42's medical record, when reviewed on 11/17/09 at 2:45 p.m., revealed the physician had ordered the following treatments: Moisture barrier cream to peri area and buttocks QS and PRN, Check placement of tab alert Q shift, Sensor pad to bed, check placement Q shift, and [MEDICATION NAME] cream 1% apply to entire back BID and PRN. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #42's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #42 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. f) Resident #76 Resident #76's medical record, when reviewed on 11/17/09 at 2:50 p.m., revealed the physician had ordered the following treatments: Aspercreme to (L) hip and neck BID, Mupirocin 2% - apply around suprapubic cathter TID (three times daily) until healed [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus). Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #76's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #76 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. g) Resident # 78 Resident #78's medical record, when reviewed on 11/17/09 at 3:00 p.m., revealed the physician had ordered the following treatments: Apply [MEDICATION NAME] lotion to feet QD (every day) and as needed, [MEDICATION NAME] 2.5% with [MEDICATION NAME] lotion apply to face BID. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #78's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #78 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. h) Resident #111 Resident #111's medical record, when reviewed on 11/17/09 at 2:15 p.m., revealed the physician had ordered the following treatment: Corn pad to right 2nd digit once daily and PRN until resolved. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #111's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #111 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. i) Resident #112 Resident #112's medical record, when reviewed on 11/17/09 at 3:20 p.m., revealed the physician had ordered the following treatments: O2 SATS QS- if Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #112's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #112 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done.",2015-10-01
9552,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,241,D,0,1,5V2011,"Based on observation, resident interview, and staff interview, the facility failed to ensure the grooming needs of one (1) resident of random opportunity were promptly addressed. Resident identifier: #95. Facility census: 157. Findings include: a) Resident #95 On 11/18/09 at approximately 10:30 a.m., observation of Resident #95 revealed she had long hair on her chin. The resident related she had a broken left shoulder, which prevented her from doing things like trimming the hair on her chin. She said she would like to have the hair removed. On 11/18/09 at approximately 11:00 a.m., the registered nurse (Employee #146) was informed the resident wished to have the hair removed. She indicated they would assist the resident with the hair removal.",2015-10-01
9553,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,281,D,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of the West Virginia Nurse Practice Act, the facility failed to meet professional standards of care for one (1) of twenty-one (21) sampled residents. The facility's nursing staff failed to follow a physician's orders [REDACTED]. Facility census :157. Resident identifier: #25. Findings include: a) Resident #25 Resident #25's medical record, when reviewed on 11/19/09 at 1:30 p.m., revealed a [AGE] year old female who was admitted to the facility on [DATE]. The resident was alert and oriented and had been determined by her physician to possess the capacity to understand and make informed healthcare decisions. The resident was on bedrest due to a fall at home resulting in fractures to the lumbar spine. The physician ordered an indwelling Foley urinary catheter for seven (7) days on 11/01/09 due to excoriation. No additional physician's orders [REDACTED]. Resident #25, when observed in bed at 1:45 p.m. on 11/19/09, had in place an indwelling urinary catheter. The resident, when interviewed, reported she did not want the catheter removed until she was off of bedrest and able to ambulate. Staff interview with the director of nurses (DON - Employee #165), on 11/20/09 at 3:15 p.m., confirmed the resident did not have a current physician's orders [REDACTED]. According to the West Virginia Nurse Practice Act for Registered Professional Nurses (W.V.C. 30-70-1), Registered professional nursing shall mean the performance for compensation of any service requiring substantial specialized judgement and skill based on knowledge and application of principles of nursing derived from biological, physical and social sciences, such as responsible supervision of a patient requiring skill in observation of symptoms and reactions and the accurate recording of the facts, or the supervision and teaching of other persons with respect to such principles of nursing, or in the administration of medications and treatments AS PRESCRIBED BY a licensed physician or a licensed dentist, or the application of such nursing procedures as involve understanding of cause and effect in order to safeguard life and health of a patient and others. (Capitalization added for emphasis.)",2015-10-01
9554,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,309,D,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed, for three (3) of twenty-one (21) sampled residents with orders to have their heels floated and/or the application of pressure relieving devices, to provide necessary care and services to assure their heels were free from unrelieved pressure. Resident identifiers: #19, #118, and #15. Facility census: 157. Findings include: a) Resident #19 Review of Resident #19's medical record found a physician's orders [REDACTED]. Observations, conducted with the assistance of a nursing staff member (Employee #187) on 11/17/09 at 3:40 p.m., found a pillow had been placed beneath Resident #19's feet. The resident's right heel was resting on the pillow, and the left heel was resting directly on the bed. Employee #187 agreed the resident's heels were not being floated. b) Resident #118 Review of Resident #118's medical record found a 10/28/09 physician's orders [REDACTED]. Further review found a physician's orders [REDACTED]. 1. Observations, conducted with the assistance of a nursing staff member (Employee #187) on 11/17/09 at 3:40 p.m., found a pillow had been placed beneath Resident #118's feet. The pillow had flattened and allowed the resident's right heel to rest on the bed. Employee #187 stated the facility was utilizing specialized pillows to float residents' heels and were doing away with the HeelzUp devices. She agreed the pillow in place at the time of this observation was not assuring the resident's heels were floated. 2. During random observations of the facility on 11/19/09 at 3:15 p.m., Resident #118 was found in a geriatric chair in the main dining room. No heel lift boot was on her left foot. A subsequent observation, in the main dining room at 12:00 p.m. on 11/20/09, found Resident #118 in a geri chair with no heel lift boot on the resident's left foot as ordered by the physician. c) Resident #15 Medical record review revealed this resident had a physician's orders [REDACTED]. At 3:45 p.m. on 11/18/09, an observation was made with the director of nursing (DON), to determine if the resident's heels were being floated as ordered. When the DON lifted the sheet and blanket from the resident's feet, observation revealed the resident was wearing heel lift boots. Medical record review revealed the boots were a previous order which had been discontinued on 11/10/09, when the physician ordered the heels to be floated when the resident was in bed. The resident's heels were not being floated as ordered.",2015-10-01
9555,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,315,D,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, policy review, and staff interview, the facility failed to assure one (1) of twenty-one (21) sampled residents received services to restore as much normal bladder function as possible. This resident's bladder incontinence was not assessed, and interventions were not implemented to assist the resident to restore or improve normal bladder function. Resident identifier: #57. Facility census: 157. Findings include: a) Resident #57 Medical record review, on 11/17/09, revealed this resident was admitted to the facility on [DATE]. The admission minimum data set noted the resident was frequently incontinent of bladder. Review of the medical record revealed a bladder patterning and analysis worksheet dated 10/26/09 - 10/28/09, which had been only sporadically completed. On 11/18/09, the director of nursing (DON) was asked if additional information might be available. At 12:00 p.m. on 11/18/09, the DON reported it was facility policy to begin a bladder assessment upon admission and that the appropriate form was included in the admission information for every resident. The policy was provided and reviewed with the DON. At that time, the DON confirmed the policy had not been implemented for Resident #57; she also confirmed the assessment, which was started on 10/26/09, had also not been completed as required by facility policy. During an interview with the resident at 3:15 p.m. on 11/18/09, the resident's bladder incontinence was discussed. The resident stated she usually could feel the urge to urinate. Further interview revealed the resident would like an opportunity to be evaluated to determine to what extent her continence might be restored.",2015-10-01
9556,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,332,D,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to assure residents were free of a medication error rate of five percent (5%) or greater. Nurses failed to give ordered medication or failed to give the correct dosage of medication to two (2) of seven (7) randomly observed residents. This resulted in five (5) medication errors with an opportunity for forty (40) errors. The medication error rate was twelve and eight-tenths percent (12.8%). Resident identifiers: #112 and #66. Facility census: 157. Findings include: a) Resident #112 During observations of the medication administration pass on 11/17/09, the licensed practical nurse (LPN - Employee #195), when preparing medications for Resident #112, skipped a page in the medication administration record (MAR). The LPN did not administer [MEDICATION NAME] 40 mg, [MEDICATION NAME] 17 GM, a multivitamin, and [MEDICATION NAME] 3000 units. She did, however, initial the MAR to indicate she had administered these medications. After observing the nurse administer medications to Resident #13, she was asked to review the MAR for Resident #112. She was shown the page with the five (5) medications which she had initialed but not administered. She agreed she had missed this page when preparing the medications. b) Resident #66 During observations of the medication pass on 11/17/09 at 7:30 a.m., the LPN (Employee # 54), while preparing Resident #66's 8:00 a.m. medications, poured one (1) 25 mg tablet of [MEDICATION NAME] into the medication cup. The LPN then administered the medication to the resident. Resident #66's medical record, when reviewed on 11/17/09 at 8:15 a.m., indicated the physician had ordered [MEDICATION NAME] 75 mg twice a day. Employee #54, when interviewed on 11/17/09 at 8:20 a.m., confirmed the resident did not receive 75 mg of [MEDICATION NAME] as ordered by the physician. The LPN stated, I am going to give her the other two tablets now.",2015-10-01
9557,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,356,C,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Review of the POS [REDACTED]. Additionally, the nurse staffing data was not posted in a clear and readable format. These deficient practices had the potential to affect all residents and visitors to the facility. Facility census: 157. Findings include: a) Random observations of the facility entrance, on 11/17/09 at 10:30 a.m., found the facility had posted the nurse staffing data in a locked display case. Review of the POS [REDACTED]. Further review revealed the nurse staff data included three (3) registered nurses (RNs) on the day shift. An interview with the staffing and scheduling coordinator (Employee #145) was conducted at 11:00 a.m. on 11/17/09. When asked about the nature of the job duties performed by the three (3) RNs listed on the posting, she relayed one (1) of the RNs did treatments and the other two (2) were unit managers. When prompted, Employee #145 was unable to state any resident direct care provided by these two (2) RN unit managers. An interview with the unit manager of building 2 (Employee #40), on the afternoon of 11/19/09, elicited what duties the unit manager routinely performed. Employee #40 stated when she first comes on duty, she checks physician's orders [REDACTED]. She relayed that a part of her shift consisted of any intravenous sticks, flushing ports, and occasional feeding of residents at lunch and dinner. The facility posting indicated all duties performed by these two (2) RN unit manager constituted direct care, which was not the case. Further Review of the POS [REDACTED]. When interviewed at 11:00 a.m. on 11/17/09, Employee #145 identified this posting to mean seven (7) LPNs and one (1) treatment nurse. Posting Tx to represent an additional LPN would not be clear to residents and visitors without medical backgrounds. The facility failed to assure that only nurse staffing hours devoted to direct care were posted as required, and failed to assure the staffing data was posted at the beginning of each shift.",2015-10-01
9558,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,364,F,0,1,5V2011,"Based on taste testing, recipe review, and staff interview, the facility failed to assure foods were flavorful. Seasoning was not added as required by recipes for three (3) food products which were sampled. This practice had the potential to affect all residents who were provided nourishment from the dietary department. Facility census: 157. Finding include: a) At 11:20 p.m. on 11/18/09, foods were sampled for seasoning. Mashed potatoes, pureed broccoli, and regular broccoli did not appear to be well seasoned. The assistant dietary manager (ADM) was asked to taste test these products. The ADM tasted the products and stated the products needed more salt. At that time the ADM directed the cook to add salt to the products. Review of the recipes for these food products revealed specific directives for seasonings. Upon inquiry, the cook confirmed the recipes for these food products had not been followed that day.",2015-10-01
9559,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,368,F,0,1,5V2011,"Based on observation, review of the facility's meal schedule, and staff interview, the facility failed to assure there were no more than fourteen (14) hours between a substantial evening meal and breakfast the following day. The span between these meals was actually greater than fifteen (15) hours. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 157. Findings include: a) On 11/18/09 at 4:25 p.m., residents who resided in Building #1 were observed to have already been served the evening meal in the dining room. Review of the facility's meal schedule revealed the meals had been served according to the schedule. Further review of the schedule revealed each area for meal service was scheduled for greater than fifteen (15) hours between the evening meal and breakfast the following day. Interview with the administrator, on 11/19/09 at 3:00 p.m., revealed she was not aware the meal span requirement was that each resident was to have no more than fourteen (14) hours between the evening meal and breakfast the following day without each resident receiving a nourishing snack and without agreement from a resident group.",2015-10-01
9560,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,371,F,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 157. Findings include: a) During the initial tour of the dietary department on 11/16/09 at 1:30 p.m., a dietary employee (#171) was observed [MEDICATION NAME] no sanitation techniques and was contaminating the kitchen area as follows: 1. She touched the inside of a waste can when she tossed something into the can and then did not wash her hands. She then walked to the area where the menu was kept and touched the menu. Next she walked over to a food cart containing foods ready to be served and pushed it to another area. 2. Employee #171 was then observed washing dishes. She washed her hands, but there was no waste can in the area. When it was not clear as to how she had disposed of the paper towels, an inquiry was made of her at 1:40 p.m. on 11/16/09. She stated she had thrown the paper towels into the large barrel just outside the dish room door. The barrel was noted to be covered. Upon inquiry, Employee #171 demonstrated that she had opened the cover with her plastic apron. After this demonstration, she was observed in the walk-in cooler pushing a cart containing food ready to be served while wearing the contaminated apron. Further inquiry revealed she had also not changed her apron the first time she lifted the trash barrel lid with the apron. b) At 1:50 p.m., another dietary employee was observed using a cleaning cloth which had been obtained from the cleaning cloth container. Upon inquiry, this person stated she had not prepared the solution in the container, so she did not know whether or not the water in it contained any type of sanitizing solution. This person was asked to check the concentration of the solution but was unable to locate a test strip. Several dietary employees, including the dietary manager, searched for the test strips but were unable to locate them at that time. Further inquiry revealed no evidence the cleaning cloth solution was checked for adequate sanitizing concentration on a routine basis. There were no logs, and staff was unable to describe when this task was performed.",2015-10-01
9561,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,428,E,0,1,5V2011,"Based on record review and staff interview, the facility failed to ensure the pharmacist's report of irregularities was reviewed and acted upon by the attending physician in a timely manner. This was true for four (4) of twenty-one (21) sampled residents. Physicians were not notified of drug irregularities by the pharmacist in a timely manner. Resident identifiers: #77, #89, #57, and #95. Facility census: 157. Findings include: a) Resident #77 Resident #77's medical record, when reviewed on 11/16/09 at 4:00 p.m., indicated the consulting pharmacist reviewed the resident's drug regimen on 10/29/09 and identified a drug irregularity. The recommendation sheet was not found in the medical record. The director of nurses (DON - Employee #165), when interviewed on 11/20/09 at 11:25 a.m., confirmed the pharmacist's report of irregularities, dated 10/29/09, was not present and available for the physician to review in the medical record. The DON reported the pharmacist failed to send the report to the facility and attending physician in a timely manner. b) Resident # 89 Resident #89's medical record, when reviewed on 11/17/09 at 3:00 p.m., indicated the consulting pharmacist reviewed the resident's drug regimen on 10/28/09 and identified a drug irregularity. The recommendation sheet was not found in the medical record. The DON, when interviewed on 11/20/09 at 11:25 a.m., confirmed the pharmacist's report of irregularities, dated 10/28/09, was not present and available for the physician to review in the medical record. The DON reported the pharmacist failed to send the report to the facility and attending physician in a timely manner. c) Resident #57 Medical record review, on 11/17/09, revealed the consultant pharmacist indicated an irregularity had been identified on 10/28/09, and this information was recorded on the consultation report. This report had not been provided by the pharmacist until the DON asked for it upon request of the surveyor. d) Resident #95 The medical record review for Resident #95, conducted on 11/20/09 at approximately 3:00 p.m., revealed the resident had a medication regimen review from 10/29/09. On this review, the pharmacist marked the section See report for any noted irregularities. This report was not present on the medical record. The assistant director of nursing provided the report at approximately 4:00 p.m. on 11/20/09.",2015-10-01
9562,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,431,E,0,1,5V2011,"Based on observation, staff interview, and review of the manufacturer's package insert, the facility failed to date a multi-dose vial of Aplisol (Mantoux) when opened. This was true for one (1) medication refrigerator observed. One (1) multi-dose vial of Aplisol (Mantoux), was not labeled with the date the medication vial was initially opened. The manufacturer recommends the medication be discarded after thirty (30) days to ensure potency. This practice has the potential to affect all residents reside in the unit who received Aplisol (Mantoux) injections. Facility census: 157. Findings include: a) On 11/17/09 at 11:00 a.m., the medication refrigerator in building #1 was observed to have one (1) open multi-dose vial of Mantoux which was not labeled with the date the vial was initially opened. The director of nurses (DON - Employee #165), when interviewed on 11/17/09 at 4:30 p.m., observed the vial in the medication refrigerator and confirmed the Mantoux vial was opened and not labeled with the date opened. The DON discarded the vial. The DON, when interviewed on 11/20/09 at 2:30 p.m., reported the facility did not have a written policy regarding dating multi-dose vials of medications. The DON, when interviewed again on 11/20/09 at 3:00 p.m., provided a copy of the manufacturer's package insert. The manufacturer's package insert from JHP Pharmaceuticals states: Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. The DON confirmed multi-dose vials of Mantoux needed to be dated to ensure the medication's effectiveness.",2015-10-01
9563,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,441,E,0,1,5V2011,"Based on observation and staff interview, the facility failed to assure each staff member implemented practices to limit the potential spread of infections. A housekeeping aide did not utilize proper hand sanitization prior to completing ice pass. This practice had the potential to affect all residents who resided on B Hall. Facility census: 157. Findings include: a) At 3:40 p.m. on 11/18/09, a housekeeping aide (Employee #198) was observed passing ice on B Hall. Observation revealed she hugged a resident, then resumed passing ice without washing or otherwise sanitizing her hands. This information was immediately brought to the attention of the director of nursing (DON - Employee #165), who intervened and instructed the employee to throw out the ice, sanitize the ice chest and any affected water pitchers, then resume the ice pass with sanitized hands. Upon inquiry at 3:45 p.m. on 11/18/09, the DON confirmed the employee had not washed or hands or sanitized them by any other means.",2015-10-01
9564,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,492,F,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on medical record review and staff interview, it was determined the facility failed to provide information regarding hospice to one (1) of twenty-one (21) sampled residents. This resident had an order for [REDACTED].C.16-5C-20. Resident identifier: #5. Facility census: 157. Findings include: a) Resident #5 Medical record review, on 11/19/09, revealed the physician had ordered comfort measures only on 09/25/09. At that time, the facility did not provide information regarding hospice. The resident's physical condition improved, and the health care surrogate decided not to continue with comfort measures only. The resident's physical condition subsequently declined again. A care plan meeting was held, with the surrogate present, on 10/09/09. At that time, the surrogate decided comfort measures only was in the best interest of the resident. On 10/13/09, the physician ordered, DNR, Comfort Care, and No labs. This information was brought to the attention of the social worker at 9:25 a.m. on 11/20/09. At that time, it was revealed that hospice information had not been provided to the resident / family on either occasion in which comfort measures were ordered. --- Part II -- Based on staff interview and review of individual food service worker's permits, the facility was not in full compliance with local laws regarding food handler's cards. Three (3) of nineteen (19) dietary personnel, who were currently working, did not have a food handler's card and/or a food handler's card from the county in which the facility is located. This practice has the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 157. Findings include: a) On 11/17/09, copies of food handler's cards were reviewed for the facility's dietary employees. The copies provided did not contain the cards for three (3) dietary staff, including the current dietary manager (Employees #13, #50, and #190). An inquiry was made of the administrator (ADM), who checked on the situation and confirmed Employees #13 and #50 did not have current food handler's cards. The ADM stated Employee #190 had a food handler's card that had been issued by another county. It was unknown whether the current county had a reciprocal agreement with the other county, so the ADM contacted the local health department and learned there was no reciprocal agreement. This meant that Employee #190 also did not have a food handler's card, according to the laws of the county in which he was working.",2015-10-01
9565,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,514,D,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure each resident's medical record was accurate. An allergy was incorrectly identified for one (1) resident, and nursing notes did not reflect the current status of another resident. Resident identifiers: #15 and #89. Facility census: 157 Findings include: a) Resident #15 Medical record review, on 11/18/09, revealed this resident was admitted on [DATE]. Documentation in the record revealed the resident was allergic to plastic. It was unknown whether the allergy had been noted upon admission or at a later date. The noted allergy was of concern, because the resident had the potential to come in contact with plastic at the facility. The allergy was brought to the attention of the director of nursing (DON - Employee #165) on 11/18/09. The DON contacted the family. At 5:00 p.m. on 11/18/09, the DON reported the resident was not allergic to plastic. The resident's chart was then clarified to reflect this information. b) Resident #89 Resident #89's medical record, when reviewed on 11/17/09 at 10:00 a.m., revealed a [AGE] year old female who was readmitted to the facility on [DATE]. The resident was scheduled to receive [MEDICAL TREATMENT] three (3) times weekly at a renal center. Nursing notes, dated 11/01/09 at 6:25 p.m., stated, Sent to RGH Hospital for eval. Temp 102.5. Vomiting. Non responsive. IN an interview on 11/20/09 at 8:15 a.m., the DON acknowledged the documentation in the 11/01/09 entry was not complete and did not reflect an accurate and complete assessment of the change in the resident's condition. According to the American Health Information Management Association (AHIMA) Long Term Care (LTC) Guidelines, A complete record contains an accurate and functional representation of the actual experience of the individual in the facility. It must contain enough information to show that the facility knows the status of the individual, has adequate plans of care and provides sufficient documentation of the effects of the care provided. Documentation should provide a picture of the resident, including what resident said or did, observations and/or assessments by staff, communications with practitioners and legal representative, response to interventions/treatment. Good practice indicates that for functional and behavioral objectives the clinical record should document change toward achieving care plan goals.",2015-10-01
9566,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2012-10-09,441,D,1,0,9WM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide signage at the entrance of rooms of residents who were to be isolated due to having infectious organisms. Failing to provide signage to alert visitors and/or staff to see the nurse before entering the room, and/or giving guidance as to what precautions are necessary when entering the room, created the potential to spread infectious organisms. Two (2) of six (6) isolation rooms observed had no signage present. Resident identifiers: #128 and # 59. Facility census: 148. Findings include: a) Resident #128 Observation on 10/08/12, at approximately 12:50 p.m., found a small cart in the hallway near the room of Resident #128. There was no signage at the door to see the nurse before entering, or instructions as to what precautions should be taken before entering the room. A speech therapy employee was observed sitting in the chair beside the resident's bed, watching him eat some food. She was not wearing gloves or a gown. A brief interview at the nurses' station, on 10/08/12, at approximately 1:00 p.m., with Employees #76 and #192 (nurses), found the isolation cart belonged to Resident #128 who was in a private room, but they were unsure why he was in isolation. Employee #192 stated Resident #128's nurse was in the dining room, and she would go ask her. Upon her return only minutes later, Employee #192 reported that his nurse said he had ESBL (extended-spectrum class A beta-lactamase), an infectious organism resistant to multiple antibiotics), in his urine. When asked if they typically post signage at the door to alert those wishing to enter his room, she applied in the affirmative. She then placed a sign instructing visitors to see the nurse before entering. Review of the medical record on 10/09/12, at approximately 2:00 p.m., found a new physician's orders [REDACTED]. However, at the time of the observation on the previous day, this had not been known. b) Resident #59 Observation, on 10/08/12, at approximately 1:15 p.m., found a small cart near the room of Resident #59. There was no signage at the door to see the nurse before entering, or instructions as to what precautions should be taken before entering the room. The Director of Nursing said Resident #59 was in contact precautions due to having Clostridium difficile (C-diff), an infectious gastrointestinal organism. She agreed there should be signage at the door to inform entrants of the need for contact precautions, as their policy dictated, and there was not.",2015-10-01
9567,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2012-10-09,514,C,1,0,9WM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that all physicians' telephone and/or verbal orders for lab work, and orders to initiated if the resident spiked a fever, were complete and accurately dated and transcribed. This was evident for one (1) of six (6) sampled residents. Resident identifier: #151. Facility census: 148. Findings include: a) Resident #151 Medical record review, on 10/09/12, found a telephone order obtained by nurse Employee #51 from the physician, dated 07/16/12. The physician ordered a urinalysis and culture and sensitivity for Resident #151. On the same physician's orders [REDACTED]. Another physician's telephone order, obtained by Employee #51, dated 07/16/12, directed to begin [MEDICATION NAME] (an antibiotic), 500 milligrams (mg.) daily if the temperature spiked again to 101 degrees. There was no time inscribed on the latter physician's orders [REDACTED]. Review of the July 2012 Medication Administration Record [REDACTED]. one tablet daily if the temperature spikes again to 101 degrees, for urinary tract infection [MEDICATION NAME]. There was no indication on the MAR indicated [REDACTED]. There was no directive on the MAR indicated [REDACTED]. Further review of the MAR found that no doses of [MEDICATION NAME] had ever been administered in July. Review of a history and physical examination [REDACTED]complaint of cough and decreased oxygen saturation.of 56%, and was in respiratory distress. The physician noted in this report the resident had a temperature of 101 degrees two days before the hospitalization , and that he (the physician) had started him on oral [MEDICATION NAME]. The admitting [DIAGNOSES REDACTED]. During an interview with the director of nursing (DON) and the Administrator, on 10/09/12, at approximately 3:30 p.m., the DON said there was no documentation that Resident #151 had ever had a fever in July. She stated her belief was that the nurse, Employee #51, read communication notes about Resident #151 (that were not part of the medical record), and thought he had had a fever on 07/15/12 when he did not. This had prompted her to relay erroneous information to the physician. Based in part on those non-medical record notes, the DON said she also did not believe the nurse transcribed the orders dated 07/16/12 the way the physician intended. The DON agreed the physician did sign the telephone order forms, dated 07/16/12, as the nurse had written them. She acknowledged there were no dates on the telephone physician order [REDACTED]. During a telephone interview with Employee #51, on 10/09/12 at 5:25 p.m., she said she could not recall anything about the resident's fever, what date or shift it may have spiked, or anything about the orders, as it happened too long ago.",2015-10-01
10612,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2011-09-21,225,D,1,0,CW0X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the facility's resident concern forms, staff interview, and review of policies and procedures, the facility failed to assure allegations of mistreatment, abuse, neglect, and/or misappropriation of resident property (made by a resident or any person acting on behalf of a resident) were reported to State officials as required by law. Review of the facility's concern forms found allegations of abuse / neglect that were not immediately reported to State officials as required by law. This deficient practice was true for three (3) of thirty-five (35) grievance / concern forms reviewed, involving two (2) residents. Resident identifiers: #132 and #157. Facility census: 153. Findings include: a) Resident #132 1. Review of the facility's resident concern forms found a record of a complaint voiced by Resident #132 dated 08/03/11, stating: ""1. Resident complaining that her buttocks has been hurting and staff haven't been putting the cream on which is provided by the facility. 2. Ears packed and needs cleaned out. 3. Teeth aren't being cleaned regularly. 4. Flies in the room. 5. Roommates BSC (bedside commode) didn't have a lid on it and when asked to fix this the nurse just pulled the curtain. 6. Resident was cold and asked for the air conditioner to be turned down and the family heard per telephone a staff member turning it up. 7. When the current roommate was admitted she yelled for several nights and kept the pt. (patient) awake. When family complained (name of nurse) explained that the issue would be resolved in six hours. They took (name of this resident) to the dining room during this time and the issue was resolved. There are no current issues between pt. (patient) and the roommate. The family doesn't understand why pt. (patient) had to remain in the dining room. 9. Sunday 07/31 (name of resident) and (name of another resident) were left in the dining room from breakfast time until after lunch. They were yelling for help and no one checked on them. They called (name of other resident's sister) from (name of other resident's) cell phone to call for help."" Although not all the individual concerns constituted allegations of abuse or neglect, the resident did allege she did not receive goods and services necessary to avoid physical harm and mental anguish and that she was a victim of involuntary seclusion, both of which should have been reported to State officials. Further review of the concern form revealed the following documented as a resolution to the above: ""Order written for [MEDICATION NAME] BID (two times a day) to coccyx on 08/08/11. Will refer to wound team and [MEDICATION NAME] and irrigation of order written. Oral care inservice in progress to all CNA's (certified nursing assistants)."" - During an interview with the administrator and director of nursing (DON) on the morning of 09/21/11, the administrator explained the facility had investigated the allegations and had taken statements from staff but had not reported the allegations to State officials. There was no evidence the facility reported the allegations of neglect / neglect to State officials when the resident voiced the above concerns on 08/03/11. - Review of the facility's policy and procedure entitled ""Abuse, Neglect and Misappropriation of Patient Property Prevention"" revealed: ""... The center must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the center and to other officials in accordance with state law through established procedures (including to the state survey and certification agency). ..."" - The Office of Health Facility Licensure and Certification (OHFLAC) Abuse Reporting Memorandum (2001) directs: ""Reporting requirements: a facility must immediately report all allegations of mistreatment, neglect, abuse or misappropriation of resident property, made by a resident or any person acting on behalf of a resident to the administrator of the facility in accordance with State law through established procedures (including to the State survey and certification agency). ..."" - 2. Further review of the resident concern forms found a record of a complaint voiced by Resident #132 to a nursing staff member on 08/20/11, stating: ""Resident stated CNA was putting her to bed and bumped her leg on the bed and threw her onto the bed."" The resolution to this concern was: ""Witness statement obtained from CNA."" Further review of the facility's documentation related to this concern revealed a statement signed by Resident #132 stating: ""Asked & asked them to put me to bed messed all over myself. The big tall girl came in asked her to lay me up on the bed. She just picked me up and threw me."" - Review of the nursing notes, dated 08/19/11 at 8:30 p.m., revealed: ""Resident c/o (complained of) aid (sic) bumping her leg on bed. 4 x 3 1/2 cm (centimeter) hematoma noted. New NA (nursing assistant) assigned per res. (resident) request, ice applied to area. Scheduled pain med. given. Dr. (name of physician) on call and (name of medical power of attorney) notified."" The facility also completed an incident / accident report on 08/19/11. - The ""Abuse / Neglect Reporting Requirements for West Virginia Nursing Homes and Nursing Facilities"" (revised November 2009) requires facilities to report as follows: ""Alleged Perpetrator is a NURSE AIDE whose identity is known -> Report to Nurse Aide Program."" - When the administrator and DON were interviewed on the morning of 09/21/11, the administrator stated the facility had investigated the allegation but did not report it to State officials, because they did not substantiate abuse or neglect. -- b) Resident #157 review of the resident concern forms found a record of a complaint voiced by Resident #157 dated 07/01/11, stating: ""Resident stated she put cream on groin, I asked her to put more cream on me my hips and my private. She stated I don't have any more cream. I told her there was some in drawer. She stated if you don't like it here, you can go somewhere else."" The resolution to the resident concern was: ""Explained to resident that CNA could not put [MEDICATION NAME] cream on him, the nurse had to. The staff makes frequent rounds to check on him. I observed frequent rounds by staff, resident stated it was misunderstanding."" Further review of the facility's documentation related to this concern revealed a statement from Employee #46 (a registered nurse - RN) dated 07/02/11, stating: ""This is my statement regarding concern from (Resident #157). I leave a written report every am (morning) that discussed this situation. Apparently, no one read it. (Name of certified nursing assistant) was the CNA involved. She came to me the morning this happened and told me that he had asked for more cream on his buttocks and she told him she didn't have anymore. She said he fussed at her until she admitted saying, 'If you don't like it here, go to another facility.' When she told me that she had said that, I educated her right then that: #1 we can't say that to our residents #2 never say it again #3 if she did say it, there was a chance she could be fired. I told her she needed to go to (Resident #157's) room & apologize & ask him if he would like to talk to the nurse supervisor. She went in the room and he didn't want to speak with me. I continued on my way to Station I. When this occurred, I was concerned if (Resident #157) was fussing. That is unlike him. I suggested a U/A (uranalysis) but I reinforced to (name of CNA) that this was unacceptable to say things like this to any of our residents, even if they are rude."" - When the administrator and DON were interviewed on the morning of 09/21/11, the administrator stated the allegation had been investigated, but it was not reported to any State officials. .",2015-01-01
11420,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2010-11-02,242,E,,,U2Q611,". Based on staff interview and record review, the facility failed to identify and communicate to direct caregivers the residents' preferences with respect to what time of day they were to receive showers. This was evident for at least seventeen (17) of twenty-two (22) residents who routinely received showers during the night shift. Resident identifiers: #7, #15, #23, #24, #38, #43, #44, #48, #52, #61, #70, #76, #81, #92, #93, #82, and #50. Facility census: 150. Findings include: a) Residents #7, #15, #23, #24, #38, #43, #44, #48, #52, #61, #70, #76, #81, #92, #93, #82, and #50. Interviews with nursing staff working night shift on 10/24/10 and 10/25/10 revealed residents were being given showers and baths during this shift. A review of shower documentation sheets revealed residents were scheduled and listed as having been given a shower or bath at various times throughout the night shift. Staff stated, in confidential interviews, they showered or bathed anywhere from one (1) to three (3) residents this shift each day except Sunday. There was no evidence, via record review, to reflect the facility staff made efforts to ascertain whether the practice of bathing during the hours of night shift was either a personal preference or customary routine of the residents or whether the practice was acceptable to the residents, as it may require awakening sleeping residents to perform this task. Review of care plans for these residents, on the morning of 11/02/10, found the care plans addressed the need for assistance with bathing, but they did not indicate what time of day each resident preferred to bath or shower. Interview with the administrator, on the morning of 11/02/10, again revealed there was no evidence that permission had been obtained from each of these residents or responsible parties to provide showers or baths to the residents during the night shift. .",2014-03-01
11421,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2010-11-02,279,E,,,U2Q612,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure the interdisciplinary care team developed a comprehensive care plan, to include measurable objectives and timetables, to meet each resident's medical and nursing needs for two (2) of ten (10) sampled residents. Resident identifiers: #150 and #151. Facility census: 142. Findings include: a) Resident #150 Review of Resident #150's medical record found a nursing note, written at 3:20 a.m. on 11/27/10, documenting the resident was sent to the emergency room for rectal bleeding with clots. He returned to the facility on [DATE]. Review of the current care plan, on 01/06/11, found no care plan for monitoring and assessment for gastrointestinal (GI) bleeding. An interview with the DON, on 01/06/11 at 11:40 a.m., confirmed the potential for GI bleeding should have been included in the comprehensive care plan. -- b) Resident #151 Review of the medical record found that Resident #151 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission orders [REDACTED]. Review of the current care plan, on 01/06/11 at 4:35 p.m., confirmed the care plan did not include interventions for [MEDICAL CONDITION] precautions. .",2014-03-01
11422,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2010-11-02,425,E,,,U2Q611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on review of medical records, review of reports from the facility's provider pharmacy and consultant pharmacists, staff interviews, review of the facility's pharmacy policy and procedure for adverse drug reactions, review of a list of drugs with the potential to interact with Coumadin, and the manufacturer's sheet for Coumadin, it was determined the facility had not implemented pharmaceutical services procedures to minimize medication-related adverse consequences or events. One (1) resident who was receiving Coumadin was ordered Bactrim DS for an infection. The resident fell and was later hospitalized . She was found to have subarachnoid bleeding. The hospital physician identified this may have occurred due to the resident receiving Bactrim DS and warfarin (Coumadin). The records of thirty (30) residents who were receiving warfarin were reviewed. Thirteen (13) were found to have orders for medications known to have major interactions with warfarin (a blood thinner). There was no evidence the potential for interactions had been identified by the pharmacists. Additionally, the facility's pharmacy manual included a policy which included notification when there was a potential adverse drug reaction (ADR). There was no evidence this policy had been implemented for residents receiving warfarin. Resident identifiers: #46, #145, #100, #27, #23, #137, #29, #52, #142, #128, #149, #90, #105, and #131. Facility census: 150. Findings include: a) Residents #46, #145, #100, #27, #23, #137, #29, #52, #142, #128, #149, #90, #105, and #131 A review of residents receiving the medication warfarin was prompted by a complaint allegation. On the morning of 10/26/10, a request was made for copies of the physicians' orders for residents who were receiving warfarin. A copy of the facility's policy for adverse drug reactions was also requested. Copies of the orders for thirty (30) residents were provided the afternoon of 10/26/10. The ordered medications were compared to the lists of drugs with a potential to interact with warfarin identified on the manufacturer's drug insert. These were further reviewed via the Internet at Drugs.com. Thirteen (13) of the thirty (30) residents were found to have one (1) or more drugs listed as having the potential to have major interactions with warfarin. All thirty (30) residents were receiving medications that had a potential to interact with warfarin, ranging from minor to moderate to major. For example: 1. Resident #29 This resident had an order for [REDACTED]. She was also receiving Gemfibrozil twice a day for [DIAGNOSES REDACTED]. This medication was listed on the manufacturer's package insert as having the potential, alone or in combination, to increase PT/INR response. According to the information found at Drugs.com, this medication was known to have the potential for a major interaction with warfarin. Bactrim DS, an antibiotic, was added to the resident's medication regimen on 10/10/10 and first administered on 10/11/10. According to information found in the manufacturer's package insert and Drugs.com, this medication also had a known potential to increase the PT/INR. 2. Resident #52 This resident was also receiving warfarin. Her other medications and potential interactions included: Fenofibrate - major Fluconazole - major Lovenox - major Cymbalta - minor Levothyroxine - moderate Omeprazole - moderate Ropinirole - moderate (She had been readmitted from the hospital on [DATE]) 3. Resident #137 The resident was receiving warfarin. Ciprofloxacin was ordered for twice a day for ten (10) days on 10/19/10. Ciprofloxacin is listed as having a major potential for interacting with warfarin. - b) The facility provided a copy of a policy / procedure regarding adverse drug reactions (ADR) as requested. This included: ""Warfarin Interactions a) Determine if the drug interaction potential is serious and predict the timing of the interaction effect as advised by FDB (First Data Bank) . b) Recommend an alternate medication if possible (i.e. azithromycin instead of erythromycin or clarithromycin) or determine if a warfarin dosage adjustment is indicated. Determine the appropriate INR monitoring frequency if needed. Call the facility and document the intervention on Policy Form #038.3A and record any order or INR monitoring changes at the bottom as directed by the physician. c) If the interaction is NOT immediate or serious the dispensing pharmacist documents their review and assessment by overriding the hang-up in the computer and printing the FDB drug interaction sheet. d) The FDB drug interaction sheet is sent with the medication delivery or faxed to the facility. . . ."" Random review of the residents receiving warfarin did not find any evidence of such notifications. The director of nursing was asked for copies of pharmacy recommendations the facility had received. She stated she had them back to May 2010. Approximately one hundred-forty (140) documents from the pharmacy to the facility were reviewed. The majority of these were regarding medication interchanges or need for hand written prescriptions for controlled substances. Only one (1) document addressing the potential for drug-drug interactions was found. This was for Resident #131. On 10/27/10, the consultant pharmacist provided a report that included, ""____ takes warfarin (Coumadin) and is also on other medications which may have pharmacodynamic and / or pharmacokinetic interactions: furosemide, acetaminophen, Lexapro, metoprolol, Nexium, and Ropinirole."" The recommendation included, ""When changing doses, stopping or starting other medications in a resident on warfarin, please consider more frequent INR monitoring, until stable."" On 11/02/10 at 12:20 p.m., the ADR policy was discussed with the director of nursing (DON). She stated the pharmacy had not been sending the notices referenced in the policy. A short while later, the DON reported they had received a list of drugs that interacted with warfarin. On 11/02/10 at approximately 4:20 p.m., Employee #192 provided a copy of the document the DON had referenced. The document listed antibiotics and anti-infectives that interacted with warfarin. Among the drugs listed under the heading ""HIGH SEVERITY : Serious risk - Action must be taken"" were Bactrim, Ciprofloxacin, and Fluconazole. Next to this list of medications was ""Notify physician for warfarin dose reduction (as necessary) and repeat PT/INR per physician recommendation."" --- Part II -- Based on review of medical records, staff interviews, review of sign-out sheets for the emergency drug box in Building 2, and a counting of the number of doses of Bactrim DS in the emergency drug box, it was determined an accurate accounting of the dispensing of medications from the emergency supply had not been ensured. Resident identifier: Unknown, but possibly Resident #29. Facility census: 150. Findings include: a) Resident #29 an order for [REDACTED]. Review of Resident #29's medical record found the antibiotic had been scheduled to be started at 9:00 a.m. on 10/11/10. However, the box for the nurse's initials on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In an interview at 9:57 a.m. on 10/27/10, Employee #53 said she had gotten the antibiotic from the emergency box. Then she paused and said she had given Tylenol, not the antibiotic. According to documentation on the MAR, Resident #29 did not receive the first dose of the antibiotic until 9:00 p.m. on 10/11/10. On 10/27/10 at 3:35 p.m., Employee #36 was asked to provide access to the emergency box. The sign out sheets were located in the medication room. According to the sheet for October 2010, no Bactrim DS had been administered from the emergency box. The information on the sheet indicated there should have been twenty (20) doses of Bactrim DS in the box. An actual count of the medication found there were nineteen (19) doses, not twenty (20) doses of Bactrim DS in the emergency box. It was unknown to whom the medication had been given. .",2014-03-01
11423,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2010-11-02,153,D,,,U2Q611,". Based on a review of the State Board of Review hearing notice, staff interview, family interview, and a review of a Release of Medical Record form, the facility failed to ensure a resident or his / her legal representative had the right, upon an oral or written request, to access all records pertaining to his/her stay at the facility, including current clinical records, within twenty-four (24) hours (excluding weekends and holidays) of receipt of the request. This occurred for one (1) of eleven (11) residents included in the sample. Resident identifier: #162. Facility census: 150. Findings include: a) Resident #162 During a telephone interview on 11/01/10 at 7:30 p.m., Resident #162's legal representative reported the facility did not allow access to the resident's medical record for review prior to an appeal for discharge hearing with the State Board of Review at 1:00 p.m. on 09/27/10. The representative reported having called the facility on 09/23/10 or 09/24/10 and leaving a voice message for the assistant administrator, asking to review the information the facility was going to use in the hearing. She said she was not provided the information prior to the hearing. During an interview on 11/02/10 at 11:00 a.m., the assistant administrator reported the request was made on 09/24/10 (a Friday) and, at that time, the information was being gathered by the facility administrator for the hearing. He said the information was not available for review until the hearing at 1:00 p.m. on 09/27/10. Review of the hearing notice, dated 09/20/10, found a second page with a section titled, ""You Have the Right To:"" The first item under this title stated, ""1. Examine all documents and manual sections to be used at the hearing, both before, during, and after the hearing. Please call the nursing home if you wish to look at the evidence before the hearing."" The administrator, who was interviewed on 11/02/10 just after the assistant administrator, stated the resident's legal representative did not ask to review the resident's records until after the hearing on 09/27/10, and she produced a release signed by the resident's legal representative on that date. .",2014-03-01
11424,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2010-11-02,309,G,,,U2Q611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, staff interview, and review of facility records, policies, and procedures, the facility failed to provide ongoing assessment / monitoring for and failed to obtain timely medical intervention for one (1) of eleven (11) sampled residents who simultaneously received [MEDICATION NAME] (an anticoagulant) and Bactrim DS (an antibiotic that potentiates anticoagulant effects) from 10/11/10 through 10/15/10. Resident #29 was found on the floor in her room (an un-witnessed fall) on the morning of 10/14/10. The day shift nurse on 10/14/10 recorded the fall in the nursing notes, noting no injury was apparent at the time. No further entries were made in the resident's nursing notes until 3:20 p.m. on 10/15/10, when the evening shift nurse noted the presence of bruising with hematoma to the resident's left temple and noted the resident appeared to have difficulty opening her left eye. The evening shift nurse contacted the attending physician, who stated that he had not previously been informed of the resident's fall and ordered that she be sent to the hospital emergency room for evaluation, as she was on a blood thinner. The resident was transported to Hospital #1's ER, where she was noted to have critical lab values related to her anticoagulation therapy and subarachnoid bleeding. The resident was later transferred to Hospital #2, where she was admitted to its neurology intensive care unit. According to the Hospital #2 discharge summary, Resident #29's subarachnoid hemorrhaging was ""secondary to over anticoagulation from [MEDICATION NAME] and Bactrim drug interactions as well as increased blood pressure as well as a traumatic fall. ..."" Nursing assistants on the early afternoon of 10/14/10 and the morning of 10/15/10 reported to the licensed nursing staff that Resident #29 had a bruise to her left temple, but no on-going neurologic assessments were completed by the licensed nursing staff after the initial assessment occurred shortly after the fall on the morning of 10/14/10, the physician was not notified of the fall or subsequent bruising to the resident's temple until the afternoon of 10/15/10, and no one at the facility recognized and/or was monitoring the resident for increased anticoagulant effects associated with administering Bactrim DS with [MEDICATION NAME]. Resident identifier: #29. Facility census: 150. Findings include: a) Resident #29 Record review revealed this [AGE] year old female was admitted to the facility in 2002. Her active [DIAGNOSES REDACTED]. The resident was receiving [MEDICATION NAME] ([MEDICATION NAME]) 6.5 mg and 7 mg alternating every other day, according to the physician's monthly recapitulation of orders for October 2010. Review of a lab report, dated 10/07/10, for [MEDICATION NAME] time (PT) and international normalized ratio (INR), both of which were used to evaluate blood clotting time, found the PT to be high at 28.5 (normal range is 11.9 - 25.4) and the INR to be within normal limits (WNL) at 2.7 (normal range is 2.0 - 3.0). The physician was notified and ordered the same dosage of [MEDICATION NAME] with a recheck of labs in four (4) weeks. Previously, on 09/07/10, Resident #29 ' s PT was elevated at 25.9 and her INR was WNL at 2.1, and no change in medication was ordered. Review of the nursing notes found an entry, dated 10/10/10 at 6:15 p.m., stating the physician was notified that the resident had an increased temperature of 101.9 degrees Fahrenheit (F). The physician ordered Tylenol 500 mg and a urinalysis (UA) and complete blood count (CBC) stat. The results were called to the physician on 10/10/10 at 11:00 p.m., and the physician ordered Bactrim DS was ordered twice daily for seven (7) days. Her temperature at this time was 98.7 degrees F. Review of the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 10/12/10 at 1530 (3:30 p.m.), the nurse's notes indicated the resident's legal representative was notified of the resident having a urinary tract infection, of her increased temperature on 10/10/10, and of the new order for Bactrim DS. The resident's temperature at this time was noted at 97.0 degrees F. On 10/13/10 at 1:00 a.m., the nursing notes indicated the resident's was not having any signs or symptoms of adverse reactions associated with the use of the antibiotic. She remained afebrile, denied pain / discomfort, and was resting in bed with eyes closed. The next nursing note, written by a licensed practical nurse (LPN - Employee #137) and dated 10/14/10 at 7:20 a.m., stated, ""Res(ident) found in floor @ bottom of bed. Res states she is OK, no visible injuries.... Res states she was going to the bathroom and fell , bed alarm was not on. Assessment completed, (symbol for 'no') c/o (complaint of) pain or discomfort. Will continue to monitor."" In this same note, the nurse recorded her vital signs as follows: blood pressure (B/P) - 138/78; pulse - 78; respirations - 18; temperature - 98.8 degrees F; O2 sat was 93% on room air. Oxygen was reapplied, and her O2 sat was 95%. The next nursing note, written by a registered nurse (RN - Employee #166) and dated 10/15/10 at 3:20 p.m., stated, ""Staff report pt (patient) had fall on 10/14/10. Noted bruising /c (with) hematoma to (L) (left) temporal area. Appeared to have difficulty opening (L) eye. Resident alert & speech clear. Pupils equal & reactive. B/P this am (morning) 136/64, O2 sat 90%, (pulse) 86, (respirations) 18. Dr. (name) notified & made aware of current status. Dr. (name) stated he was unaware of fall. New order received to send resident to (Hospital #1) ER for evaluation. Resident is currently on blood thinner. POA (power of attorney) was notified."" The next nursing note, dated 10/15/10, at 4:15 p.m. stated, ""TC from (Hospital #1) ER. Resident being sent to (Hospital #2); has a subarachnoid bleed."" -- 2. Review of Hospital #1's records found Resident #29 had critical lab values of PT greater than 100 (normal range is 20.5 - 30.0, with critical values greater than 39), INR of 11.9 (normal range is 2.5 - 3.5, with critical values greater than 4.0), and PTT (partial [MEDICAL CONDITION] time) of 83 (normal range is 27 - 32) on 10/15/10 at 1526 (3:26 p.m.). The resident's red blood cells were low at 3.61 (normal range is 4.5 - 6.3), hemoglobin was low at 11.6 (normal range is 12.1 - 15), hematocrit was low at 33.9 (normal range is 35.8 - 46). The results of a CT scan of Resident #29's brain without contrast, dated 10/15/10, noted: ""Findings: There is punctate hemorrhage of the left frontal lobe. There is no extra axial component. There is a large, left frontal scalp hematoma. Sulcal and ventricular prominence correlation with atrophy. There is no midline shift. There is no calvarial fracture."" Under the heading CT Brain Impression was: ""1. Acute left frontal lobe parenchymal hemorrhage. 2. Generalized cerebral atrophy. 3. Large, left, frontal scalp hematoma."" The resident received 8 units of fresh frozen plasma and 30 mg of Vitamin K and was transferred to Hospital #2's neurology intensive care unit for a neurosurgical consultation on 10/15/10; she was subsequently admitted there at 2352 (11:52 p.m.), according to Hospital #2's discharge summary. -- 3. The discharge summary from Hospital #2, dated 10/20/10, under the heading Admission History and Physical stated: ""This was a transfer from (Hospital #1). The patient initially is a resident at Heartland of Beckley. The patient apparently fell down. The patient was not taken to the hospital at that time. After a day (sic) refer to consultation with the family. The patient was sent to (Hospital #1). At Hospital #1, the patient was found to have (sic) subarachnoid hemorrhages. The patient was subsequently transferred to the Neuro ICU here at (Hospital #2) for neurological evaluation. On presentation to (Hospital #1), patient ' s blood pressure was 170/74. The patient's INR was noted to be 11.9. The patient did receive a course of Bactrim previously while at Heartland of Beckley."" Under the heading Hospital Course was stated, ""... I believe patient's subarachnoid hemorrhage is secondary to over anticoagulation from [MEDICATION NAME] and Bactrim drug interactions as well as increased blood pressure as well as a traumatic fall. ..."" -- 4. Review of the resident's resident assessment protocol (RAP) for falls with an effective date and time of 06/29/10 at 11:09 a.m. stated, "" ... resident was walking back from bathroom and slid and fell (sic) improper footware (sic) pt educated on use of proper footware (sic) improper footware (sic) removed (sic) assessed for injury (sic) none noted (sic) neuro checks started (sic) md and poa aware."" An off-cycle falls RAP, with an effective date of 10/14/10 at 08:34 a.m., was completed by one (1) of the assistant directors of nursing (ADON - Employee #192) and signed on 10/16/10. It stated, ""Fall care plan reviewed and remains in place. No new recommendations made during IDT (interdisciplinary team) review."" - The Care Plan Focus for ""At risk for falls due to Cognitive (sic) impairment, pain, unsteady gait, walks without assistance, low oxygen saturations from not wearing oxygen, [MEDICAL CONDITION]"", which was initiated on 04/11/07, contained the goal of ""No injury requiring transfer to hospital."" The following interventions to achieve this goal were initiated on 04/11/07: ""Monitor for and report development of pain, bruises, change in mental status, ADL function, appetite or neurological status for at least 72 hours after a fall. Administer medications as ordered and monitor for effectiveness. Minimize environmental clutter. Have commonly used articles within easy reach. Encourage to transfer and change positions slowly. Reinforce need to call for assistance. Encourage and assist as needed to wear proper and non slip footwear. Encourage to use assistive devices: walker."" On 10/04/07, the IDT added: ""Give medication as ordered."" On 12/31/08, the IDT added: ""Educate staff to not leave resident unattended."" On 06/25/09, the IDT added: ""Educate resident on the use of call light and asking for assistance."" On 09/24/09, the IDT added: ""Sensor pad to bed at all times."" On 10/18/09, the IDT added, ""Anti-rollbacks to W/C (wheelchair)."" On 03/19/10, the IDT added: ""non (sic) skid shoes as tolerate (sic)."" (Note that several of the ""newer"" interventions were very similar to interventions that had been in place since 04/11/07.) - The Care Plan Focus for ""Anticoagulant therapy to treat [MEDICAL CONDITION]: At risk for adverse effects"", which was initiated on 04/11/07, contained the goal of ""Resident will have no adverse effects from anticoagulant use such as (sic) not limited to bruising, bleeding, blood in stool / emesis, etc."" Interventions to achieve this goal included: ""Monitor lab values and report results to physician. Monitor for and reports (sic) adverse effects such as blood in urine / stool, gums / nose bleeding, bruising. Provide education to family / resident about safety precautions. Administer medications per physician orders. Monitor for S/S (signs / symptoms) of [MEDICAL CONDITION] such as pain (sic) redness in ext (extremities)."" The last revision to this care plan was made on 10/27/09, beyond updating to the goal ' s target date. -- 5. The LPN who received the order from the physician on 10/10/10 at 11:00 p.m. (Employee #53) was interviewed at 9:57 a.m. on 10/27/10. Employee #53 said when she called the physician she did not tell him specifically what medications the resident was already receiving. She said the pharmacy usually calls before sending a medication if there would have been any problems with drug-to-drug interactions. - The nursing assistant (NA) who showered Resident #29 on day shift on 10/14/10 (Employee #31) was interviewed at 10:20 a.m. on 10/27/10. Employee #31 reported that, after lunch on 10/14/10, she noted a knot on the resident's head and bruising to the resident's hand, and the resident told her she fell . She said when she was on the way to the shower with the resident, she told the medication nurse (Employee #82, an LPN). He looked at the resident's head, administered a medication to the resident, and the resident was given a shower. Employee #31 said the resident was taken back to her room. She did note that the resident appeared to be having increased congestion. A review of Employee #31's statement taken by the director of care delivery (Employee #192) on 10/16/10 found the following: ""States she took over care of resident on 10/14 AM (morning) when other CNA (certified nursing assistant) was pulled to another unit. State she saw a large raised area with a bruise stating to form on resident's (L) temple area. States this was around noon, during resident ' s shower. States she brought it to the attention of the nurse '(Employee #82 ' s first name)'. States resident's behavior was normal & speech was normal."" Review of the Shower / Skin Observation Report for 10/14/10, completed by Employee #31 and signed by Employee #82, did not show any bruising or abnormalities for the resident. - The LPN who assessed Resident #29 after she was found on the floor at 7:20 a.m. on 10/14/10 (Employee #137) was interviewed at 10:25 a.m. on 10/27/10. She reported having been told of the fall by a NA (Employee #93) at the start of the shift. She said the resident was sitting in the floor upright with her legs out in front of her. The bed alarm was not on and was not sounding. She said she did a head-to-toe assessment of the resident and found no bruising or signs of injury. She indicated she checked the resident's head, back, and legs, as she was afraid the resident might have broken a hip. She also said she thought she started a neurological evaluation flow sheet but was told it could not be found. A review of Employee #137's statement taken by Employee #192 on 10/14/10 at 0830 (8:30 a.m.) found the following: ""Nurse stated that resident had a fall around 0730 and that she found no apparent injuries. Stated resident denied any pain or discomfort. States she notified Dr. (name) and MPOA (medical power of attorney) of the fall and completed an incident report. State she initiated neuro checks because the fall was not witnessed. No noted abnormalities at that time."" Elsewhere in witness statement for was written: ""Staff member became ill shortly after the incident and was taken to the hospital by EMS. Unable to locate neuro check sheet."" - The resident's October 2010 MAR indicated [REDACTED]. Review of the MAR for 10/14/10 found Employee #82 only gave the resident [MEDICATION NAME] 100 mg at 2:00 p.m. on that date, as he was reassigned to that area when Employee #137 was sent out to the emergency room . He stated, ""(Employee #31) said the resident had a bruise on her head. I looked at it. I went out and looked at the book for acute documentation. I did not know if it was documented. I don't recall saying anything to (Employee #134) who I reported off to (at 3:00 p.m.)."" A review of Employee #82's statement taken by Employee #192 on 10/16/10 found the following: ""Stated he took over med cart for nurse that left due to illness, along with (Employee#134), LPN. States he did note a bruise to the L temple area of the resident, but (sic) had been told it was already there from a fall. States he did not know when the fall occurred."" - An interview was conducted, on 10/27/10 at 11:30 p.m., with the LPN who received report from Employee #82 at 3:00 p.m. on 10/14/10 (Employee #134). Employee #134 said she worked from 7:30 to 4:00 p.m. on 10/14/10 as a treatment nurse. The October 2010 treatment record was reviewed with her at this time. She said she checked the resident's sensor pad and oxygen on 10/14/10, but she did not remember at what time. She thought it was before breakfast (before 8:30 a.m.). She reported that she helped Employee #82, after Employee #137 was sent out to the emergency room , with medications and doing treatments. She did not know anything about the resident's fall on 10/14/10. - A review of a statement taken from Resident #29 by Employee #192 on 10/15/10 revealed the following: ""Resident sitting up on side of bed. Bruising noted to (L) temple / forehead area. Resident alert and answering appropriately to my questions. When asked if she had any pain, she answered, 'my head'. When asked if she remembered fall she stated, 'I'm not sure'. When asked where her head hurt she stated 'Inside and out'. Resident sent to (Hospital #1) within 30 minutes of my conversation with her."" - A review of a statement taken from Employee #72 (a nursing assistant) by Employee #192 on 10/15/10 revealed the following: ""CNA states that she noted a bruise to the (L) temple area of the resident around 0830 (8:30 a.m.) on the morning of 10/15/10 when she took her breakfast tray to her. States that the nurse was aware of the bruise at that time."" - A review of a statement written on 10/18/10 by Employee #166 (a registered nurse assigned to Resident #29 on the morning of 10/15/10) revealed the following: ""I had a wing and part of another wing (we were short nurses). I received report from night shift (name). No mention of a fall or injury to the resident was made during report. I gave her morning meds first. I noticed bruising to the left side of her temple area. I took her VS (vital signs) and they were normal. I had to wake her to take her meds. She was 'groggy' but sat up and took her pills for me. I questioned some other staff and they stated she had a fall the morning before. I assumed her bruising was from the fall. When I reviewed the chart there was no documentation of any injury. I recognized the resident was on [MEDICATION NAME]. I went to assess her neurologically and found her to be WNL but C/O pain to (L) eye. I notified Dr. (name) of fall (sic) 10/14 & injury noted @ this time. Dr. (name) stated he was not notified and asked that resident be sent to ER."" -- 6. Review of the pharmacy manual's policy titled ""Adverse Drug Reaction"" from Omnicare, Inc (last revised 01/10/06), which was provided by the facility ' s administrator at approximately 9:00 a.m. on 10/27/10, found: ""ROCEDURE: The pharmacy will identify potential ADRs (adverse drug recations) by reviewing any drug therapy that appeared to cause: - Discontinuation of therapy - Patient hospitalization - Treatment with another drug used for allergic reactions - Significant patient illness - Threat to life or death. ""The pharmacist will document the potential adverse drug reaction on the Adverse Drug Reaction Log ... noting severity level. ""The pharmacy operating system is set to identify First Data Bank (FDB) levels 1, 2, and 3 drug interactions for the dispensing pharmacist at the time of order entry. ""The dispensing pharmacist evaluates the potential seriousness and immediacy of the drug interaction in the individual using their professional judgment and the information provided by FDB. Factors such as the person's age, comorbidities, and concurrent drug therapies area taken into consideration ..."" ""[MEDICATION NAME] Interactions: ""a) Determine if the drug interaction potential is serious and predict the timing of the interaction as advised by FBD. ""b) Recommend an alternate medication if possible ... or determine if a [MEDICATION NAME] dosage adjustment is indicated. Determine the appropriate INR monitoring frequency if needed. Call the facility and document the intervention ...."" -- 7. Review of the facility's policy titled ""Neurological: Neurological Evaluation"" (dated 3/2010) found: ""PURPOSE: A neurological evaluation is used to establish a baseline neurological status upon which subsequent evaluation may be compared and changes in neurological status may be determined. ""USE: - Following a witnessed fall (when a patient has hit his/her head) - Following an un-witnessed fall (when a head injury may be suspected) - Following a patient event which results in a known or suspected head injury (i.e.: hemorrhagic stroke) ... ""PROCEDURE: ""1. Initiate and document a baseline neurological evaluation as indicated on the Neurological Evaluation Flow Sheet. ""2. Notify physician of specific patient event, initial findings, and baseline neurological evaluation. ""3. Obtain orders for subsequent neurological evaluations, diagnostic studies or other medical care. ""4. After the completion of initial neurological evaluation with vital signs, continue evaluations every 30-minutes x 4, then every 1-hour x 4, then every 8-hours x 9 (for the next 72 hours). ""NOTE: More frequent neurological evaluations may be necessary if clinically indicated or as ordered per physician. ""5. Subsequent neurological evaluation should be compared to baseline and previous neurological evaluations. ""6. Evaluate level of consciousness and document 'Y = Yes or N = No' responses to the following: - Alert - Lethargic - Semi-comatose - Comatose ""7. Evaluate level of orientation and document 'Y = Yes or N = No' responses to the following: - Oriented to person - Oriented to place - Oriented to situation ""8. Evaluate pupils. (It may be necessary to darken room or ask patient to close eyes for 30 seconds prior to evaluation.) Upon opening eyes, use a penlight or flashlight to evaluate Pupil Size and Pupil reaction for both the left and right eyes. Document using the following responses: - E = equal pupil size - U = unequal pupil size - R = reacts to light - NR = no reaction to light ""9. Evaluate motor movement by providing patient with simple motor commands. Document 'Y = Yes or N = No' responses to the following: - Moves right upper limb - Moves left upper limb - Moves right lower limb - Moves left lower limb - Facial symmetry ""10. Evaluate communication / language by providing simple communication commands. Document 'Y = Yes or N = No' responses to the following: - [MEDICAL CONDITION] - Receptive [MEDICAL CONDITION] - Speech slurred - Communication changes ""11. Evaluate for unusual / new observations. Document observation responses using the following: - W = Weakness - T = Tremors - D = Dizziness - H = Headache - V = Vision changes - N = Numbness - O = Other ""12. Evaluate vital signs. Record baseline vital signs and compare subsequent vital signs to baseline and previous evaluations. Document the following information: - Blood pressure - Pulse - Pulse Ox % (Oxygen Saturation) - Temperature - Respiration rate - Respiration pattern -- N = Normal / Regular / Unlabored -- AB = Abnormal (i.e.: Labored, Kussmaul's , Cheyne-Stokes or Apnea) ""NOTE: Pay close attention to respiratory patterns. Notify physician regarding any 'Abnormal' findings or any changes in respiration rate or pattern. ""NOTE: Notify physician of any neurological evaluation findings which are a change from baseline or previous evaluations. Document physician notification in Progress Notes. ""13. Notify the family / caregiver of patient condition an devaluation findings. ""14. Communicate event, interactions, and plan of actions using center specific systems (i.e. shift to shift reports, 24-Hour Reports, Eagle Room team meeting and alert charting)"" - Random confidential nursing staff interviews found that evidence of ongoing neurological evaluations of Resident #29 could not be found. Although Employee #137 (who first assessed her after she was found on the floor on the morning of 10/14/10) reported she completed an initial neurological exam, evidence of that initial assessment could not be found. This lack of on-going neurologic assessments was confirmed during an interview at exit with the facility administrator at 4:30 p.m. on 11/02/10. -- 8. The facility's ""Practice Models Charting Alert"" (dated 08/11/06) stated: ""Purpose: To provide a guideline for the clinical documentation process that may be needed following a change in patient condition or status ""Guidelines: The alert charging process includes documentation of a patient's condition that warrants alert charging, the decisions and actions of staff related to the patient's condition and the patient's response to interventions implemented - Situation for alert charting typically include new admission monitoring needs, acute change of patient condition or situations that are expected to resolve or stabilize within. Some examples may include, but are not limited to: -- Change of condition, e.g. flu symptoms -- Accidents -- New admission or re-admissions -- Signs and symptoms of infection -- Skin alterations, e.g., skin tear, bruise, rash - The Alert Charting process includes, but is not limited: -- Documentation of patient evaluation findings, physician notifications and responses, family notification and any new orders or instructions received in the interdisciplinary progress notes or nursing notes -- Initiation of an Acute Care Plan including the patient ' s problem or need, goal, and interventions planned to manage the patient ' s condition -- Addition of patient name and information to the Alert Charting Log -- Update to the Change in Status Report, 24-hour Report -- Inclusion of information in shift-to shift report -- Notification of nurse supervisor, IDT members and other staff as needed -- Review of patient status during Eagle Room meetings - Documentation for alert charting occurs each shift for a minimum of 72 hours - Licensed nurses reference the Alert Charting Log at the start of each shift to identify patients requiring continued follow-up and alert documentation - Documentation related to the alert charting process may include, but is not limited to: -- Patient evaluation pertinent to the condition identified as the acute event -- Vital signs -- Presence or absence of pain -- Complaints and/ or behavior problems -- Changes in activities of daily living -- Patient response or outcomes - Remove patients form Alert Charting Log and discontinue Acute Care Plan when patient status has stabilized or the condition or symptom has resolved."" There was no evidence this practice model was implemented for Resident #29 following her fall on the morning of 10/14/10. Review of the ""Change In Status Worksheet / 24 Hour Report"" for 10/10/10 through 10/14/10 revealed no mention of Resident #29's condition and/or status except for on 10/10/10, when a nurse wrote: ""Give Tylenol 500 mg PO now D/T (due to) increased temp. U/A and CBC stat."" - The ""Change In Status Worksheet, 24-Hour Report Practice Model"" (dated 08/11/06) stated: ""Purpose: To provide an interdisciplinary communication tool that may be used to identify patient with a change in condition requiring intervention and follow-up. ""Guideline: ""- Complete form per directions and use narrative section for additional information as needed ""- Information includes but is not limited to: -- Admissions -- Unplanned discharges -- Change in condition, e.g. improvement or deterioration in physical, mental and psychological status -- Unstable condition -- Incidents / accidents -- New / discontinued medication orders -- Abnormal lab results -- Pain level > or = 4 -- Patient / family concerns -- Notification of physician, family / responsible party, administrator and/or ADNS -- Documentation completed: Nursing admission evaluation, off-cycle RAP, progress RAP, progress notes -- Nurse's initials ""- Interdisciplinary team members may enter any identified change of condition requiring clinical follow-up ""- Use report to communicate concerns at morning and after Eagle Room meetings ""- Use report during shift change to communicate patient information and needed follow up ""- Review report to confirm follow-up, notification and documentation of patient needs are complete"" - There was no evidence this practice model was implemented for Resident #29 following her fall on the morning of 10/14/10. -- 10. Review of the pharmacy manual's ""Policy #4.1 Prescriber Authorization and Communication of Orders"" (dated 12/01/07) found: ""PROCEDURE: "" ... 3. Verbal Orders: ""3.1 The facility's licensed nurses should contact the resident's physician where there is a change in condition that may require a new medication or a renewal of an existing order. ""3.1.1. Before contacting the physician / prescriber, the Facility's licensed nurses should assemble the necessary clinical information. This information may include, but is not limited to: vital signs, recent laboratory or diagnostic study results, recent medication orders, residents' response to medication, and possible adverse drug reactions."" No one at the facility recognized the possible adverse drug reaction associated with simultaneously administering Bactrim DS with [MEDICATION NAME]. .",2014-03-01
11425,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2011-01-07,520,E,,,U2Q612,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility's quality assessment and assurance committee failed to identify quality deficiencies of which it was (or should have been) aware and develop and implement plans of action to correct these quality deficiencies. This resulted in the facility's continuing non-compliance with the Medicare / Medicaid conditions of participation. During the current survey from 01/03/11 through 01/07/11, the facility failed to correct deficient practices cited during previous survey events that concluded on 09/01/01 and 11/02/10, with respect to the following regulatory requirements: Comprehensive Care Plans (F279), Quality of Care (F309), and Pharmaceutical Services (F425), resulting in repeat deficiencies in these areas. These deficient practices affected three (3) of ten (10) sampled residents and presented the potential for more than minimal harm to more than an isolated number of residents at the facility. Resident identifiers: #150, #151, and #152. Facility census: 142. Findings include: a) Quality of Care 1. The facility demonstrated non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of Quality of Care (F309) resulting in findings of deficiencies at a level of actual harm to an isolated number of residents during two (2) previous survey events at the facility, which concluded on 09/01/10 and 11/02/10. During this current survey event from 01/04/11 through 01/07/11, based on medical record review and staff interview, the facility failed to assure that necessary care and services were provided to attain or maintain the highest practicable physical and mental well-being for (2) of ten (10) sampled residents. 2. Resident #151 was initially admitted to the facility at 11:00 p.m. on 12/10/10 with [DIAGNOSES REDACTED]. The facility failed to obtain from the pharmacy in a timely manner and administer medication, in accordance with physician orders, to treat the resident's anxiety. 3. Resident #152 was admitted to the facility on [DATE] following a hospitalization for urinary tract infection [MEDICAL CONDITIONS] and [DIAGNOSES REDACTED]. Nursing staff at the facility failed to appropriately assess and monitor this resident for exacerbation of these conditions. Nursing staff failed to institute neurological assessments for Resident #152 (who was receiving [MEDICATION NAME] therapy which placed her at high risk for bleeding) following a fall sustained on 12/05/10. Nursing staff members did not begin monitoring the resident's neurological status until the evening of 12/07/10, and the director of nursing (DON), when interviewed, stated these neuro-checks should have been initiated immediately after the fall. Additionally, Resident #152, who had a [DIAGNOSES REDACTED]. (See also citation at F309.) -- b) Pharmaceutical Services (F425) 1. The facility demonstrated non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of Pharmaceutical Services (F425) resulting in findings of deficiencies presenting the potential for more than minimal harm to more than an isolated number of residents during a previous survey event, which concluded on 11/02/10. During this current survey event from 01/04/11 through 01/07/11, based on medical record review and staff interview, the facility failed to assure that pharmaceutical services were provided to meet the needs of two (2) of ten (10) sampled residents, both of whom had a [DIAGNOSES REDACTED]. 2. Resident #151 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident did not receive her first dose of [MEDICATION NAME] at the facility until the evening of 12/12/10, because the facility failed to obtain and/or fax a script to the pharmacy in a timely manner. 3. Resident #152 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This resident missed twelve (12) scheduled doses of [MEDICATION NAME] between 6:30 p.m. on 12/02/10 and 9:00 a.m. on 12/06/10, because the facility failed to obtain and/or fax a script to the pharmacy in a timely manner. (See also citation at F425.) -- c) Comprehensive Care Plans (F279) 1. The facility demonstrated non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of Comprehensive Care Plans (F279) resulting in findings of deficiencies presenting the potential for more than minimal harm to more than an isolated number of residents during a previous survey event, which concluded on 11/02/10. During this current survey event from 01/04/11 through 01/07/11, based on medical record review and staff interview, the facility failed to assure the interdisciplinary care team developed a comprehensive care plan, to include measurable objectives and timetables, to meet each resident's medical and nursing needs for two (2) of ten (10) sampled residents. 2. Resident #150, who was sent to the emergency room at a local hospital on the early morning of 11/27/10 for rectal bleeding with clots, did not have a current care plan (as of 01/06/11) to address the need to assess and monitor for [MEDICAL CONDITION]. 3. Resident #151, who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. (See also citation at F279.)",2014-03-01
11426,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2010-09-01,309,G,,,XJ0U13,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure that necessary care and services were provided to attain or maintain the highest practicable physical and mental well-being for (2) of ten (10) sampled residents. Resident #151 was initially admitted to the facility at 11:00 p.m. on 12/10/10 with [DIAGNOSES REDACTED]. The facility failed to obtain from the pharmacy in a timely manner and administer medication, in accordance with physician orders, to treat the resident's anxiety. Resident #152 was admitted to the facility on [DATE] following a hospitalization for urinary tract infection [MEDICAL CONDITIONS] and [DIAGNOSES REDACTED]. Nursing staff at the facility failed to appropriately assess and monitor this resident for exacerbation of these conditions. Nursing staff failed to institute neurological assessments for Resident #152 (who was receiving [MEDICATION NAME] therapy which placed her at high risk for bleeding) following a fall sustained on 12/05/10. Nursing staff members did not begin monitoring the resident's neurological status until the evening of 12/07/10, and the director of nursing (DON), when interviewed, stated these neuro-checks should have been initiated immediately after the fall. Additionally, Resident #152, who had a [DIAGNOSES REDACTED]. These practices had the potential to result in more than minimal harm to an isolated number of residents. Resident identifiers: #151 and #152. Facility census: 142. Findings include: a) Resident #151 Review of Resident #151's medical record found this [AGE] year old female was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of her nursing notes revealed the following consecutive entries: - The admission nursing note, dated 11:00 p.m. on 12/10/10, stated,""... Resident appeared anxious and wanted to call her niece. The Resident (sic) phone was given to Resident and this appeared to have a calming affect (sic). ... VS (vital signs) are WNL (within normal limits) excluding pulse possibly D/T (due to) anxiety experienced when first arriving. ... Resident is A/O (alert / oriented) x's (sic) /c (with) confusion noted. ... All meds sent to pharmacy STAT and pharmacy was notified and stated they would be sent. ... There appear to be (symbol for 'no') s/s (signs / symptoms) of acute distress noted at this time. ..."" - A nursing note, dated 12/11/10 at 11:45 a.m., stated,""... Alert / oriented to person, place and time, But (sic) does not answer questions appropriately. (Arrow pointing up) confusion to situation / reasons for being admitted to HL (Heartland). ..."" - A nursing note, dated 12/11/10 at 11:41 p.m., stated, ""OT (occupational therapy) orders noted ..."" - A nursing note, dated 12/11/10 (time illegible), stated, ""Res (resident) OOF (out of facility) until approx 1130 - 12 noon. Ref (refused) shower upon arrival. 'I just got back from the Hospital.' ..."" - A nursing note, dated 12/13/10 at 11:45 a.m., stated, ""A/O x 3 (alert and oriented to person, place, and time). Confusion noted, Demanding (sic) argumentative (illegible) meds, explained med regimen several times /s (without) success D/T confusion."" - A nursing note, dated 12/13/10 at 4:30 p.m., stated, ""Late entry 12/12/10 12am (sic) went to res (resident's) room to give her meds. res (sic) states 'What's this?' Explained to her that it was her night time meds. Res says 'I don't take any of that sh**! I want my nerve pill and my depression pill.' Explained to her these meds had not arrived from pharmacy. Res became upset, shouting 'What the hell is wrong with this place. The longer I'm here the worse it is.' res (sic) ref (refused) to take any meds. RN supervisor (name) answered res light right after ref meds. He spoke /c me about 'not giving her meds'. I explained situation to him, went in & offered meds again & res cont (continued) to refuse. phoned (sic) pharmacy about [MEDICATION NAME] & [MEDICATION NAME]. pharmacy (sic) states that a script is needed for [MEDICATION NAME] & [MEDICATION NAME] had been sent. ..."" Review of the resident's physician orders [REDACTED]."" Review of Resident #151's hospital records revealed the physician who examined her wrote in the ER, under the heading ""Clinical Impression"", ""Anxiety / Panic Attack"". She was treated with intravenous [MEDICATION NAME] and returned to the facility at approximately 11:30 a.m. on 12/11/10. Review of the admitting orders found the resident was prescribed [MEDICATION NAME] 1 mg twice-a-day (bid) for anxiety and [MEDICATION NAME] (generic name for [MEDICATION NAME]) 50 mg at bedtime for depression / anxiety. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s initials documented at 10:00 p.m. with the following statement, ""Refused all pm (evening) meds (medications) because [MEDICATION NAME] & depression med was not available."" Review of the MAR found the resident also did not receive her 9:00 a.m. dose of [MEDICATION NAME] 1 mg on 12/12/10. After her return to the nursing facility on 12/11/10 (after having been treated with IV [MEDICATION NAME] for anxiety / panic attack), the facility failed to obtain and administer two (2) consecutive scheduled doses of [MEDICATION NAME] to treat her anxiety. She did not receive her first dose of [MEDICATION NAME] at the nursing facility until the 9:00 p.m. dose was administered on 12/12/10. An interview with the DON, on 01/06/11, confirmed the facility did not obtain the resident's [MEDICATION NAME] until 9:25 p.m. on 12/12/10. -- b) Resident #152 1. Review of Resident #152's medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE]. According to recent assessment data, she was alert / disoriented to person, place, and season, had short and long-term memory impairment, and her cognitive skills for daily decision-making were moderately impaired. She was totally dependent on staff for the performance of all activities of daily living, had partial loss of voluntary movement with limitations in range of motion on both sides in her upper and lower extremities, and was incontinent of bowel and bladder. Her active [DIAGNOSES REDACTED]. Further review found the resident was receiving [MEDICATION NAME] 5 mg (blood thinner) daily, which placed her at high risk for bleeding. - Review of Resident #152's nursing notes found the resident was readmitted to the facility on [DATE], following treatment in the hospital for UTI [MEDICAL CONDITION]; her [DIAGNOSES REDACTED]. She went back out to the hospital on [DATE] for the insertion of a gastrostomy tube and returned to the facility again on the evening of 12/20/10. According to a nursing note dated 12/26/10 at 12:30 a.m., ""Resident sent to (initials of local hospital) ER (emergency room ). Order received via telephone from Dr. (name of physician). See SBAR (Situation / Background / Assessment / Request form)."" The next consecutive note, dated 12/26/10 at 7:10 a.m., stated, ""Called (initials of local hospital) ER. Resident admitted to (initials of local hospital) D/T (due to)[MEDICAL CONDITION], mental status change, & respiratory compromise."" Review of the electronic form referred to as the ""SBAR"", dated 12/26/10 at 12:45 a.m., found under the heading ""Situation"": ""O2 sats (blood oxygen saturation levels) decreased to 72% with O2 @ 2.5L NC (oxygen at 2.5 liters / minute via nasal cannula). airways (sic) suctioned (sic) O2 (sic) increased to 80%. NEB (nebulizer) tx (treatment) administered. Lung sounds congested. O2 icreased (sic) to 3L via NC S (sic)."" Under the heading ""Background"", the author noted that medical information pertinent to this event included, ""Fall on 7p-7a (7:00 p.m. to 7:00 a.m.) shift on 12/24/2010, recent peg tube placement, increased temp of 101.0."" The author also noted the resident had exhibited a decrease in her level of consciousness, and increased heart rate of 148 beats per minute with an irregular rhythm, wheezes when checking her lung sounds, and the resident's skin color was pale. Under the heading ""Assessment (RN) / Appearance (LPN/LVN)"", the licensed practical nurse (LPN) completing the form noted, ""Resident (sic) skin warm, clammy. Pale in color. SOB (shortness of breath) noted."" Under the heading ""Request"", the author noted having contacted the resident's physician and obtaining an order to ""Send resident to (initials of local hospital) ER. "" Review of the resident's physician progress notes [REDACTED]. (""Rhonchi"" or ""wheezes"" are abnormal breath sounds caused by air moving through airways narrowed by [MEDICATION NAME], swelling, or partial airway obstruction.) Review of nursing notes from her previous stay, from 12/02/10 to 12/13/10, revealed the resident was congested and required suctioning and aerosolized breathing treatments, with deep suctioning and a chest x-ray ordered on [DATE]. Review of her current care plan, with a print date of 09/01/10, revealed the following problem statement: ""Potential for respiratory impairment related to [MEDICAL CONDITION]."" The goal associated with this problem statement was: ""Resident will have no acute episodes of respiratory distress such as, but not limited to SOB, dyspnea, cyanosis, aspiration (sic)."" Interventions to assist the resident in achieving this goal included: ""... Monitor lung sounds and VS (vital signs) as needed. Report abnormalities to physician. ... Monitor for and report adverse changes in respiratory rate, cough, respiratory effort, sputum color / consistency. ... "" Review of nursing notes from the date of her readmission to the nursing facility on 12/21/10 until her transfer to the hospital on [DATE] found no evidence to reflect the licensed nursing staff was routinely assessing / monitoring the resident's respiratory system for abnormal breath sounds after the physician identified the presence expiratory rhonchi, although the licensed staff periodically noted the resident's respiratory rate and blood oxygen saturation levels. - Further review of the resident's current care plan found the following problem statement: ""Urinary incontinence related to effects of [MEDICAL CONDITION]."" The goal associated with this problem statement was: ""Will have no complications due to incontinence such as, but not limited to UTI, skin breakdown (sic)."" Interventions to assist the resident in achieving this goal included: ""...Monitor for and report any changes in amount, frequency, color or odor of urine or continency (sic). ... Monitor for and report any S&S (signs and symptoms) of UTI such as flank pain, c/o (complaints of) burning / pain, fever, change in mental status, etc ..."" The medical record contained no nursing notes or other evidence that licensed nursing staff was assessing / monitoring the resident for signs and symptoms of UTI. - The resident was admitted to the hospital on [DATE] with a temperature of 101.0 degrees Fahrenheit (F); the resident's hospital [DIAGNOSES REDACTED]. - 2. Review of Resident #152's medical record found a nursing note, dated 12/05/10 at 2:30 p.m., documenting that Resident #152 sustained a witnessed fall. A nursing note, dated 12/07/10 at 10:00 p.m., documented the following, ""... Resident did have a fall on 12/5/10 at 2:30 p.m. Neuro Checks started at 10 pm to rule out neurological damages..."" Because of her daily use of [MEDICATION NAME], Resident #152 would have been at high risk for intracranial bleeding if she had struck her head as a result of this fall. Review of the neurological evaluation flow sheet found that nursing staff did not begin monitoring the resident for potential neurological compromise until 10:00 p.m. on 12/07/10, approximately fifty-five (55) hours after the resident's fall. In an interview was conducted on 01/07/11 at 3:45 p.m., the director of nursing (DON - Employee #15) was asked when nursing staff should have started neuro checks after the resident's fall. The DON stated that neuro checks should not have waited and staff should have started them immediately. - 3. Medical record review also revealed Resident #152 was readmitted to the facility on [DATE] at 6:30 p.m. with a [DIAGNOSES REDACTED]. Review of the MAR found Resident #152 received no [MEDICATION NAME] from her date of re-entry on 12/02/10 at 6:30 p.m. until 9:00 p.m. on 12/06/10. A nursing note, written on 12/05/10 at 5:30 p.m., documented the nurse called the medical director to inform him of the resident not receiving [MEDICATION NAME]. The note also documented the medical director instructed the nurse to wait until Monday and contact the resident's treating physician to obtain a prescription to be faxed to the pharmacy. The resident missed twelve (12) doses of ordered [MEDICATION NAME] due to the facility's failure to obtain pharmaceutical services in a timely manner. .",2014-03-01
11427,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2011-01-07,425,E,,,XJ0U13,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure pharmaceutical services were provided to meet the needs of two (2) of ten (10) sampled residents, both of whom had a [DIAGNOSES REDACTED]. Resident identifiers: #151 and #152. Facility census: 142. Findings include: a) Resident #151 Review of Resident #151's medical record found this [AGE] year old female was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admitting orders found the resident was prescribed Xanax 1 mg twice daily for anxiety and Doxepin 50 mg at bedtime for depression / anxiety. Review of her nursing notes revealed a note, dated 12/13/10 at 4:30 p.m., stating, ""Late entry 12/12/10 12am (sic) went to res (resident's) room to give her meds. res (sic) states 'What's this?' Explained to her that it was her night time meds. Res says 'I don't take any of that sh**! I want my nerve pill and my depression pill.' Explained to her these meds had not arrived from pharmacy. Res became upset, shouting 'What the hell is wrong with this place. The longer I'm here the worse it is.' res (sic) ref (refused) to take any meds. RN supervisor (name) answered res light right after ref meds. He spoke /c me about 'not giving her meds'. I explained situation to him, went in & offered meds again & res cont (continued) to refuse. phoned (sic) pharmacy about Xanax & Sinequan. pharmacy (sic) states that a script is needed for Xanax & Sinequan had been sent. ..."" Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the back of the MAR found a nurse's initials documented at 10:00 p.m. with the following statement, ""Refused all pm (evening) meds (medications) because Xanax & depression med was not available."" Further review of the MAR indicated [REDACTED]. She did not receive her first dose of Ativan at the nursing facility until the 9:00 p.m. dose was administered on 12/12/10. An interview with the DON, on 01/06/11, confirmed the facility did not obtain the resident's Xanax until 9:25 p.m. on 12/12/10. -- b) Resident #152 Review of the medical record found Resident #152 was readmitted to the facility on [DATE] at 6:30 p.m. with [DIAGNOSES REDACTED]. Review of the MAR found Resident #152 received no Xanax from her date of re-entry on 12/02/10 at 6:30 p.m. until 9:00 p.m. on 12/06/10. A nursing note, written on 12/05/10 at 5:30 p.m., documented the nurse called the medical director to inform him of the resident not receiving Xanax. The note also documented the medical director instructed the nurse to wait until Monday and contact the resident's treating physician to obtain a prescription to be faxed to the pharmacy. The resident missed twelve (12) doses of ordered Xanax due to the facility's failure to provide pharmaceutical services in a timely manner. .",2014-03-01
11512,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2010-09-01,312,E,,,XJ0U11,". Based on record review, resident interview, and staff interview, the facility failed to assure residents were provided personal hygiene as needed and as planned by the facility. Each resident had scheduled shower days twice weekly. Residents were randomly selected for review from each of four (4) halls and equally from 7-3 and 3-11 shifts. Two (2) of four (4) residents residing in Building 2 did not receive showers on their scheduled days on four (4) to five (5) occasions each during the period of review from 08/01/10 through 08/31/10. These findings excluded any showers offered but refused by residents and marked on the ADL (activities of daily living) sheets as refused. Resident identifiers: #43 and #66. Facility census: 157. Findings include: a) Resident #43 Medical record review, with a registered nurse (RN - Employee #33) on 08/31/10 at 4:30 p.m., revealed this resident did not receive a scheduled shower on 08/04/10, 08/18/10, or 08/25/10 on the 3:00 p.m. to 11:00 p.m. (3-11) shift. This was three (3) of eight (8) scheduled shower days. (Refusals were not counted in the number of scheduled days for which a shower should have been provided.) At times, a bed bath was provided instead of a shower. At other times, it was not possible to ascertain what type of hygiene was provided, if any. During interview with this resident on 08/30/10, she said she likes showers but sometimes doesn't get them, because staff is too busy. When asked if this was true even recently in the past month or so, she replied in the affirmative. - b) Resident #66 Medical record review, with Employee #33 on 08/31/10 at 4:30 p.m., revealed this resident did not received a scheduled shower on 08/02/10, 08/16/10, 08/23/10, or 08/26/10 on the 3-11 shift. This was four (4) of nine (9) scheduled shower days for which the resident did not refuse a shower. (Refusals were not counted in the number of scheduled days for which a shower should have been provided.) At times, bed baths were provided instead of a shower. At other times, it was not possible to ascertain what type of hygiene was provided, if any. - c) During interview with Employee #33 on 08/31/10 at 4:30 p.m., she said residents are showered twice weekly, and residents are care planned if they often refuse showers. She was unable to find documentation in the medical record regarding either showers or refusals of showers for the above residents on the dates listed. During interview on 09/01/10 at 10:40 a.m., Employee #218 said she had no other shower documentation regarding Residents #43 and #66 to substantiate either refusals of showers, or showers given, on the dates listed above in August 2010. - d) During confidential interviews on 08/30/10 and 08/31/10 with eleven (11) nursing assistants from both the 7:00 a.m. to 3:00 p.m. (7-3) and 3-11 shifts working in Building 2, four (4) of the eleven (11) employees (two (2) from each shift) reported having to leave some showers undone at the end of the shift in the past month. During confidential interviews on 08/30/10 and 08/31/10 with nursing assistants from both 7-3 and 3-11 shifts in Building 1, seven (7) nursing assistants reported having to leave some showers undone at the end of the shift in the past month. - e) During confidential random interviews with nursing assistants in Building 2 on 7-3 and 3-11 shifts on 08/30/10 and 08/31/10, six (6) nursing assistants stated they often have to turn and reposition by themselves residents who are care- planned to be two-person assists for that task. The reason cited was that there is not enough staff available to help them. - f) During confidential interviews with nursing assistants on 7-3 and 3-11 shifts on 08/30/10 and 08/31/10, eleven (11) of twenty-one (21) nursing assistants stated they often have to turn residents who are designated two (2) person assists by themselves due to having no one available to help them. - g) On 09/01/10 at 11:30 a.m., these findings were reported to the administrator and the interim administrative director of nursing services, and no additional information was provided. .",2014-01-01
11513,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2010-09-01,353,E,,,XJ0U11,". Based on record review, resident interview, and staff interview, the facility failed to deploy sufficient direct care staff across all shifts and units to ensure residents received personal hygiene as needed and as planned by the facility. Record review revealed two (2) of four (4) residents (#43 and #66) residing in Building 2 did not receive showers on their scheduled days on four (4) to five (5) occasions each during the period of review from 08/01/10 through 08/31/10. When interviewed, Resident #43 reported she wanted her showers but sometimes did not get them because staff was too busy. In confidential interviews, nursing assistants on both the 7:00 a.m. to 3:00 p.m. (7-3) shift and the 3:00 p.m. to 11:00 p.m. (3-11) shift reported they have not been able to complete showers as scheduled in the past month or obtain the assistance of a second staff member for turning and repositioning residents who were assessed as requiring the assistance of two (2) for bed mobility due to a lack of availability of staff. This practice has the potential to affect more than an isolated number of residents. Resident identifiers: #43 and #66. Facility census: 157. Findings include: a) Resident #43 Medical record review, with a registered nurse (RN - Employee #33) on 08/31/10 at 4:30 p.m., revealed this resident did not receive a scheduled shower on 08/04/10, 08/18/10, or 08/25/10 on the 3:00 p.m. to 11:00 p.m. (3-11) shift. This was three (3) of eight (8) scheduled shower days. (Refusals were not counted in the number of scheduled days for which a shower should have been provided.) At times, a bed bath was provided instead of a shower. At other times, it was not possible to ascertain what type of hygiene was provided, if any. During interview with this resident on 08/30/10, she said she likes showers but sometimes doesn't get them, because staff is too busy. When asked if this was true even recently in the past month or so, she replied in the affirmative. - b) Resident #66 Medical record review, with Employee #33 on 08/31/10 at 4:30 p.m., revealed this resident did not received a scheduled shower on 08/02/10, 08/16/10, 08/23/10, or 08/26/10 on the 3-11 shift. This was four (4) of nine (9) scheduled shower days for which the resident did not refuse a shower. (Refusals were not counted in the number of scheduled days for which a shower should have been provided.) At times, bed baths were provided instead of a shower. At other times, it was not possible to ascertain what type of hygiene was provided, if any. - c) During interview with Employee #33 on 08/31/10 at 4:30 p.m., she said residents are showered twice weekly, and residents are care planned if they often refuse showers. She was unable to find documentation in the medical record regarding either showers or refusals of showers for the above residents on the dates listed. During interview on 09/01/10 at 10:40 a.m., Employee #218 said she had no other shower documentation regarding Residents #43 and #66 to substantiate either refusals of showers, or showers given, on the dates listed above in August 2010. - d) During confidential interviews on 08/30/10 and 08/31/10 with eleven (11) nursing assistants from both the 7:00 a.m. to 3:00 p.m. (7-3) and 3-11 shifts working in Building 2, four (4) of the eleven (11) employees (two (2) from each shift) reported having to leave some showers undone at the end of the shift in the past month. During confidential interviews on 08/30/10 and 08/31/10 with nursing assistants from both 7-3 and 3-11 shifts in Building 1, seven (7) nursing assistants reported having to leave some showers undone at the end of the shift in the past month. - e) During confidential random interviews with nursing assistants in Building 2 on 7-3 and 3-11 shifts on 08/30/10 and 08/31/10, six (6) nursing assistants stated they often have to turn and reposition by themselves residents who are care-planned to be two-person assists for that task. The reason cited was that there is not enough staff available to help them. - f) During confidential interviews with nursing assistants on 7-3 and 3-11 shifts on 08/30/10 and 08/31/10, eleven (11) of twenty-one (21) nursing assistants stated they often have to turn residents who are designated two (2) person assists by themselves due to having no one available to help them. - g) On 09/01/10 at 11:30 a.m., these findings were reported to the administrator and the interim administrative director of nursing services, and no additional information was provided.",2014-01-01
11514,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2011-01-07,281,E,,,XJ0U13,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, review of ""Criteria For Determining Scope of Practice For Licensed Nurses And Guidelines For Determining Acts That May be Delegated or Assigned By Licensed Nurses"" (revised 06/17/09), and medical record review, the facility failed to provide goods and services in accordance with professional standards of quality, by assigning a licensed practical nurse (LPN) to complete in-depth skin assessments (including making a determination regarding the staging of pressure ulcers), an act outside her scope of practice. This practice affected one (1) of ten (10) sampled residents (#145) with the potential to affect all residents with pressure sores. The facility also failed to assure that physician orders [REDACTED]. This practice affected one (1) of ten (10) sampled residents (#152) with the potential to affect any other resident with similar physician orders. Resident identifiers: #145 and #152. Facility census: 142. Findings include: a) Resident #145 1. An interview was conducted, on 01/06/11 at 3:40 p.m., with registered nurse (RN - Employee #187) related to the care and services provided to promote healing to former Resident #145. During this interview, Employee #187 requested the assistance of the wound nurse, Employee #127 (who was an LPN). While discussing the interventions that had been put into place for Resident #145, Employee #127 described her contribution to the assessment of pressure ulcers. The LPN reported, at 3:55 p.m. on 01/06/11, that she was responsible for all the pressure ulcers of residents on the A, B, and C units of the facility. She stated she measured the wound beds; identified / described the presence of any tunneling, drainage, and colors; and staged the wounds. When asked if she had received specialized training in the assessment and staging of wounds, Employee #127 stated she did not have any additional credentials such as a wound care specialist. - 2. The administrator was asked, on the afternoon of 01/07/11, for evidence that the LPN (Employee #127) had received training or education in assessing and staging pressure ulcers. The administrator was unable to provide any evidence that this LPN had received formal training beyond entry level. - 3. Review of ""Criteria For Determining Scope of Practice For Licensed Nurses And Guidelines For Determining Acts That May be Delegated or Assigned By Licensed Nurses"" (revised 06/17/09), which was published jointly by the State's licensing boards for RNs and LPNs, found the following on page 6: ""Both the RN and LPN are responsible for implementing the nursing process in the delivery of nursing care. The Boards receive many questions about the LPN's role in the assessment component of the nursing process. While the law does not specifically address the issue of the LPN's role in the assessment process, the rule clearly places the responsibility for the analysis of the data on the RN..."" Review of page 12 found a section entitled ""Guidelines for Delegation of Nursing Acts To the Licensed Practical Nurse"", which contained the following language: ""1. Delegation of acts beyond those taught in the basic educational program for the LPN should be based on a conscious decision of the registered nurse. - Practice beyond entry level for the LPN should not be automatic nor should it be based solely on length of experience. 2. Practice beyond entry level must be competency based. - Competency based practice is defined by structured educational activities which include assessment of learning and demonstration of skills. 3. Records of educational activities designed to enhance entry level knowledge, skill and ability must be maintained and available to the RN making the decision. - The employer and the employee must maintain records which include an outline of the educational content and an evaluation of achievement of educational objectives and demonstrated skills..."" - 4. An interview with the RN assessment coordinator (Employee #48), who was responsible for the completion of the minimum data set (MDS) assessment, was conducted on 01/07/11 at 5:15 p.m. via telephone. She agreed that she was responsible for completing the pressure ulcer assessment section of each resident's MDS. When asked how she determined the stage of pressure ulcers, she stated she retrieved that information from the facility's weekly wound tool. When asked if she personally assessed resident wounds prior to completing the assessment portion of the MDS and staging the wounds, she stated she did not assess the wounds in order to complete this section of the MDS. - 5. A follow-up interview with Employee #127 was conducted via speaker phone on 01/07/11 at 6:15 p.m., in the presence of the administrator and the director of nursing (DON). Employee #127 verified she completes the weekly wound tool and stages the wounds. When asked if she received assistance in doing this from the RN, she stated, ""Very rarely do I have to ask about a wound."" -- b) Resident #152 Review of Resident #152's medical record found that, on 12/21/10 at 4:15 a.m., the physician gave the following orders: ""Hold pain medications, [MEDICATION NAME], ... [MEDICATION NAME] until BP (blood pressure) comes up. Monitor BP Q (every) 30 minutes."" 1. With respect to holding these medications in the presence of low blood pressure, the order did not contain clear and specific instructions to the licensed nurses to indicate when the resident's blood pressure was high enough to prompt the nurses to restart the medications. An interview with the DON, on the afternoon of 01/05/11, confirmed this order should have been clarified by the nursing staff. 2. With respect to the on-going monitoring of the resident's blood pressure, the order did not contain parameters to indicate at what point the licensed nurses were to discontinue monitoring the resident's blood pressure at a frequency of every thirty (30) minutes. Review of the medical record found the licensed nursing staff followed the physician's orders [REDACTED]. .",2014-01-01
11515,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2011-01-07,441,D,,,XJ0U13,". Based on random observation and staff interview, the facility failed to implement an infection control program which effectively helped prevent the potential spread of disease and infection in the facility. A staff member was observed to rinse a bed pan soiled with urine in the sink in a resident's bathroom. This same staff member also obtained drinking water from other sinks to fill residents' water pitchers. This was true for one (1) of ten (10) sampled resident. Resident identifier #105. Facility census: 142. Findings include: a) Resident #105 At approximately 11:30 a.m. on 01/04/11, Employee #33 was observed to assist Resident #105 off a bedpan. The NA (nursing assistant) emptied the urine from the bedpan into the toilet located in the resident's room. The NA then turned on the water in the resident's sink and rinsed the bedpan. This nursing assistant was previously observed filling Resident ' s water pitchers at others sinks. The NA, who was interviewed immediately following the observation, was asked what she thought about rinsing bedpans from the same sink that drinking water was obtained. The NA stated it was ""gross"" because the ""urine splashes up"". .",2014-01-01
11516,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2011-01-07,501,E,,,XJ0U13,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility's medical director failed to assume responsibility for the coordination of facility-wide medical care. There was no evidence of ongoing collaboration by the medical director with facility personnel to help develop, implement, and evaluate resident care policies and procedures to correct continuing non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of quality of care. Additionally, the medical director failed to coordinate medical care by not assuring Resident #143 received timely physician visits, and failed to assume the care of Resident #152 when nursing staff contacted him for medication for the resident, instructing staff to wait until Monday and contact the resident's treating physician to obtain a prescription to be faxed to the pharmacy. These practices affected two (2) of ten (10) sample residents during the current survey and had the potential to result in more than minimal harm to more than an isolated number of facility residents. Resident identifiers: #152 and #143. Facility census: 142. Findings include: a) The facility has had continued non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of quality of care (F309) during the last three (3) survey events at the facility, beginning with a survey event that concluded on 09/01/10, resulting in findings of deficiencies in quality of care at a level of harm. There was no evidence of ongoing collaboration with facility personnel to help develop, implement, and evaluate resident care policies and procedures to correct this continuing non-compliance. (See also citation at F309.) - b) Resident #143 Medical record review, on 01/05/11, revealed this resident was admitted to the facility on [DATE], and was discharged on [DATE]. There was no evidence this resident had a face-to-face contact, in the facility, with his attending physician between 09/06/10 and 12/17/10. On 01/05/11 at 4:30 p.m., this situation was brought to the attention of the director of nursing (DON). The DON was asked to locate any physician's progress notes which might be available. On 01/06/11, the DON reported nursing personnel was unable to produce any physician's progress notes for the resident. When this situation was brought to the attention of the facility's administrator on 01/06/10, she provided a copy of a letter written to the resident's attending physician on 10/07/09 which stated, ""This is your official notice that you have ten days to come in and complete the physician progress notes [REDACTED]. If you fail to comply with this notice it will be placed in your file."" The medical director had not assured this attending physician saw this resident in a timely manner. (See also citation at F387.) - c) Resident #152 Review of the medical record found Resident #152 was readmitted to the facility on [DATE] at 6:30 p.m. with [DIAGNOSES REDACTED]. Review of the MAR found Resident #152 received no [MEDICATION NAME] from her date of re-entry on 12/02/10 at 6:30 p.m. until 9:00 p.m. on 12/06/10. A nursing note, written on 12/05/10 at 5:30 p.m., documented the nurse called the medical director to inform him of the resident not receiving [MEDICATION NAME]. The note also documented the medical director instructed the nurse to wait until Monday and contact the resident's treating physician to obtain a prescription to be faxed to the pharmacy. The resident missed twelve (12) doses of ordered [MEDICATION NAME] due to, in part, to the medical director's failure to render assistance in obtaining the necessary medication. (See also citations at F309 and F425.) .",2014-01-01
11517,HEARTLAND OF BECKLEY,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2011-01-07,387,D,,,XJ0U13,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure one (1) of ten (10) sample residents received a physician visit in the facility at least once every thirty (30) days for the first ninety (90) days after admission. This resident, who resided in the facility from [DATE] until 12/17/10, had no face-to-face visits with his attending physician. Resident #143. Facility census: 142. Findings include: a) Resident #143 Medical record review, on 01/05/11, revealed this resident was admitted to the facility on [DATE], and was discharged on [DATE]. There was no evidence this resident had a face-to-face contact, in the facility, with his attending physician between 09/06/10 and 12/17/10. On 01/05/11 at 4:30 p.m., this situation was brought to the attention of the director of nursing (DON). The DON was asked to locate any physician's progress notes which might be available. On 01/06/11, the DON reported nursing personnel was unable to produce any physician's progress notes for the resident. When this situation was brought to the attention of the facility's administrator on 01/06/10, she provided a copy of a letter written to the resident's attending physician on 10/07/09 which stated, ""This is your official notice that you have ten days to come in and complete the physician progress notes [REDACTED]. If you fail to comply with this notice it will be placed in your file."" .",2014-01-01
926,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2017-03-23,246,D,0,1,10BJ11,"Based on observation, staff interview and resident interview, the facility failed to ensure a resident received services with reasonable accommodation of their individual needs. This was true for one (1) of thirty five (35) residents observed in Stage 1 of the Quality Indicator Survey (QIS). Resident #9, who was capable of using the call light, did not have access to their call light. Resident identifier: #9. Facility census: 77. Findings include: a) Resident #9 Observation of Resident #9, during stage one (1) of QIS, on 03/20/17 at 3:32 p.m., revealed the resident's call bell button cord tied to the bed's left side rail. The resident had contractures of the right upper and lower extremities. The resident had impaired mobility of her right arm (elbow and hand). When the resident was asked to push the call light button to see if the call system was functioning properly, the resident attempted to reach for it and was unable to reach the button. The resident said, I can't. The resident was then asked, What do you do when you can't reach the call bell and you need help with something? The resident replied, I just lay here. On 03/20/17 at 3:40 p.m., Nurse Aide (NA) #55 was outside of Resident #9's room in the hall. This surveyor requested NA#55 go into Resident #9's room to have the resident push her call light. NA #55 went in and asked Resident #9 to push her call light. Resident #9 said, I can't. I can't reach it. The resident demonstrated to NA #55 that she could not reach the button. NA#55 unfastened and lengthened the call bell cord so Resident #9 could reach and push the call bell button with her left hand. Interview with NA#55 confirmed Resident #9 could not reach the call bell button prior to NA#55 untying and moving the call bell cord, after surveyor intervention. Interview with DON, on 03/23/17 at 8:35 a.m., revealed the facility would get a call pad for Resident #9 to use, to make it easier for her to access the call system and to accommodate her needs.",2020-09-01
927,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2017-03-23,253,E,0,1,10BJ11,"Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services to ensure a sanitary, orderly and comfortable interior for ten (10) of thirty (30) rooms observed during Stage 1 of the Quality Indicator Survey. The cosmetic imperfections included privacy curtains hanging loose from hooks, missing tile, damaged sink tops, torn padding on side rail, and a scrapped wall. Room identifiers: #103, #111, #112, #113, #210, #212, #214, #215, #313, and #314. Facility census: 77. Findings include: a) Cosmetic imperfections: - Room #103 observed on 03/20/17 at 3:59 p.m., had missing tile on the on the wall around the bathtub. - Room #111 observed on 03/21/17 at 10:45 a.m., had a discolored sink top. - Room #112 observed on 03/21/17 at 11:12 a.m., had scrapped walls and a missing sink skirt. - Room #113 observed on 03/21/17 at 10:56 a.m., had a porcelain chip in the sink. - Room #210 observed on 03/21/17 at 11:36 a.m., had privacy curtains hanging loose from the hooks. - Room #212 observed on 03/20/17 at 5:34 p.m., had privacy curtains hanging loose from the hooks. - Room #214 observed on 03/21/17 at 11:14 a.m., had privacy curtains hanging loose from the hooks. - Room #215 observed on 3/21/17 at 10:59 a.m., had privacy curtains hanging loose from the hooks. - Room #313 observed on 03/20/17 at 4:09 p. m., had molding pulled away from sink top, and the padding was torn on the side rail for bed B. - Room #314 was observed on 03/20/17 at 4:05 p.m., had molding missing from the side of the sink top. b) Interview with the Maintenance Supervisor During an interview on 03/22/17 at 9:35 a.m., the Maintenance Supervisor verified the privacy curtains should hang properly, the missing tile, damaged sink tops, torn side rail padding, and the scrapped wall all needed repaired or replaced.",2020-09-01
928,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2017-03-23,371,E,0,1,10BJ11,"Based on observations and staff interviews, the facility failed to store foods in a sanitary manner and maintain clean kitchen equipment. The facility also failed to serve Resident #84's food under sanitary conditions. This practice had the potential to affect any resident receiving nourishment from the dietary kitchen and residents being served their food under sanitary conditions. Resident identifier: #84. Facility census: 77. Findings include: a) Kitchen tour During a tour of the kitchen, on 03/20/17 at 2:15 p.m., the following observations were made: --A ten (10) pound bag of fish filets, and a two (2) pound bag of biscuits in the walk-in freezer opened and not dated. --A 10 pound can of mandarin oranges had a two (2) inch dent to the rim and side of the can. The facility failed to ensure these food items were safe for consumption. --A three (3) shelf utility cart used for transferring food was found dirty with dried food particles on the third shelf and a brown colored build up on the handle and shelf supports. The facility failed to ensure the utility cart was sanitary for transporting and serving food. Interviews with the Dietary Manager and the Dietician on 03/20/17 at 2:45 p.m., verified the fish filets and biscuits were not dated after opening, the dented can of mandarin oranges should have been pulled from the rack and the utility cart was dirty and needed cleaned. b) Resident # 84 Observations of the evening meal on 03/20/17, found Resident #84 was served his meal at 5:41 p.m. by Quality Assurance Aide (QAA) #46. Resident #84's urinal, which contained urine, was sitting on his over the bed table. QAA #46 picked up the urinal and moved it to the side of the table, and then proceeded to sit Resident #84's evening meal on the over the bed table beside the urinal. He positioned the over the bed table in front of Resident #84 so that he would be able to eat his meal. QAA #46 then left the room and did not remove the residents urinal from his over the bed table. At 5:45 p.m. Licensed Practical Nurse (LPN) #72 entered Resident #84's room and spoke with him briefly and then exited the room she did not remove the urinal from Resident #84's over the bed table. LPN #72 again entered the room at 5:49 p.m. to speak with Resident #84 and again exited the room without removing the urinal from Resident #84's over the bed table. When LPN #72 exited the room on this occasion she was asked what her job was at the facility. She indicated that she was an LPN and one of the nurses who worked with the infection control program. She was then asked if Resident #84's urinal should be sitting on his over the bed table beside his meal while he was eating. She stated, No. I did not even notice that. She then entered the room and removed the urinal from Resident #84's over the bed table.",2020-09-01
929,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2018-05-16,641,D,0,1,6Z1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure two (2) of eighteen (18) residents whose records were reviewed had an accurate and complete Minimum Data Set (MDS) which reflected the residents current status. Resident #43's MDS did not reflect the resident had a fall. Resident #70's MDS did not reflect the resident was receiving an antidepressant. Resident identifiers: #43 and #70. Facility census: 80. Findings included: a) Resident #43 Review of an incident/accident report, dated 03/05/18 found the, Resident stood up to pull up her pants and when she went to sit back down, she missed the potty chair and fell on to the floor on her bottom. An x-ray was obtained and no injuries were noted. Review of the MDS, completed after the fall on 03/05/18, a quarterly MDS, with an assessment reference date (ARD) of 03/27/18, coded the resident as having no falls since the last assessment. The last assessment was a significant change MDS with an ARD of 12/26/17. At 1:00 p.m. on 05/15/18, Registered Nurse (RN) #36 confirmed the 03/05/18 MDS was incorrectly coded. At 1:20 p.m. on 05/15/18, the Director of Nursing (DON) was advised of the incorrectly coded MDS. She had no further information to present. b) Resident #70 Review of Resident #70's medical records found a physician order [REDACTED]. Review of the significant change MDS, with an assessment reference date (ARD) of 01/16/18, coded the resident received no antidepressants in the seven day look-back period. At 10:22 a.m. on 05/15/18, Registered Nurse (RN) #36 confirmed the MDS with ARD of 01/16/18 was incorrectly coded. At 11:20 a.m. on 05/15/18, the Director of Nursing (DON) was advised of the incorrectly coded MDS. She had no further information to present.",2020-09-01
930,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2018-05-16,656,D,0,1,6Z1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to develop a comprehensive person-centered care plan in the care areas of indwelling catheter and [MEDICAL CONDITION] medication. This was true for two (2) of 18 care plans reviewed. Resident identifiers: #50 and #70. The facility census was 80. Findings included: a) Resident #50 During an observation on 05/14/18 at 12:44 PM, it was noted Resident # 50 had a Foley Catheter and there was no strap securing it to her leg. An observation on 05/15/18 at 8:25 AM, with NA #51, confirmed there was no strap securing Resident #50's catheter to her leg. She was asked if there should be a strap securing the catheter to her leg to prevent injury. NA #51 said, I don't know I don't do that the nurses do. She stated, she would have the nurse to get one. During a review of the comprehensive care plan the only mention of a Foley Catheter was under the focus statement At Risk for Skin breakdown. Without any mention or direction for Foley Catheter care. During an interview on 05/15/18 at 12:36 PM, with RN #36, She agreed she should have care planned the Foley Catheter and would fix it right away. b) Resident #70 A review of Resident #70's medical records found a physician order [REDACTED]. A review of the comprehensive care plan found no mention of the use of an antidepressant. At 10:22 a.m. on 05/15/18, Registered Nurse (RN) #36 confirmed the care plan did not address the use of an antidepressant ([MEDICATION NAME]).",2020-09-01
931,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2018-05-16,684,D,0,1,6Z1211,"Based on medical record review and staff interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice. Neurological checks were not performed after an unwitnessed fall for one (1) of two (2) residents reviewed for the care area of falls and accident hazards. Resident identifier: #27. Facility census: 80. Findings included: a) Resident #27 An incident report for Resident #27 on 5/10/18 at 1:07 PM stated the following: Incident Description: Was notified that resident was found in the floor on the safe floor mat with no injury when observed. Resident unable to give. The immediate action taken stated, Staff reports that resident was checked for injury and no injury found. Unknown if this was an intentional act due to uncontrollable squirming movements. Will consider a fall at this time due to resident unable to tell us why she was moving. The incident report stated there were no witnesses to the fall. The incident report was completed by Licensed Practical Nurse (LPN) #44. The medical record contained no evidence that neurological checks had been initiated for Resident #27 after her unwitnessed fall on 5/10/18. During an interview on 05/15/18 at 1:45 PM, LPN #44 confirmed Resident #27's fall on 5/10/18 had been unwitnessed. LPN #44 also confirmed neurological checks had not been initiated after the fall. She stated facility practice is to initiate neurological checks for residents who have experienced unwitnessed falls but this was not done for Resident #27 on 5/10/18.",2020-09-01
932,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2018-05-16,690,D,0,1,6Z1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility failed to ensure two (2) of two (2) residents reviewed with indwelling Foley catheters, had catheter tubing securely anchored to prevent inadvertent catheter removal or tissue injury from dislodging the catheter. Resident identifiers: #33 and #50. Facility census: 80. Findings included: a) Resident #33. Review of the medical record found the resident was initially admitted to the facility on [DATE] with an indwelling Foley catheter for a [DIAGNOSES REDACTED]. Observation of the resident at 1:03 p.m. on 05/14/17, revealed the resident was lying in bed. The catheter tubing was running along side the bed into the catheter bag which was hooked to the bed frame. Observation of the resident with the Director on Nursing (DON) at 8:15 a.m. on 05/15/18, confirmed the catheter tubing was not properly secured to prevent removal or tissue injury from dislodging the catheter. b) Resident #50 An observation on 05/14/18 at 12:44 PM, found Resident #50 had a Foley Catheter and there was nothing securing the catheter tubing to her leg. An observation on 05/15/18 at 8:25 AM, with NA #51, confirmed there was nothing securing the catheter to Resident #50's leg. She was asked if the catheter tubing should be secured to Resident #50's leg to prevent injury. She said, I don't know, I don't do that the nurses do. NA #51 stated, she would have a nurse to get one. During an interview with Director of Nursing (DON) on 05/15/18 at 9:07 AM, she was informed about the findings. She indicated she would take care of it. c) Facility Policy A review of the Facility Policy, FOLEY CATHETER CARE dated, 07/2008. Found no mention of the use of any type of an anchoring device to secure the catheter from being pulled or tugged which could cause injury. An interview with the Administrator and the DON was conducted on 05/15/18 at 2:05 PM, in regards to the Policy not containing anything about the use of a secure device to secure the catheter to the residents legs. The Administrator said, Now we don't use those on our residents because it causes them to get skin break down. She was informed that it is part of the Regulations and it is used to prevent injury and accidental removal and that they are soft secure devices that do not attach to the skin. The Administrator then asked if this surveyor knew where she could get them or what the order number was? She said that, she would get her supply girl to look into getting something. On 05/15/18 at 2:08 PM, Inventory Personnel #14 came in the room to show this surveyor they had soft leg stabilizers to use as Foley catheter anchors.",2020-09-01
933,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2018-05-16,812,E,0,1,6Z1211,"Based on observation and staff interview, the facility failed to store food in accordance with professional standards for food safety. Food items in the 400 hallway lounge refrigerator, night pantry cupboard, and the Activities Department refrigerator were not dated when they were opened. Additionally, two items in the activities department refrigerator were past their sell-by date. This failed practice had the potential to affect more than a limited amount of residents. Facility census: 80. Findings included: a) Kitchen On 05/15/18 at 12:52 PM, observations were made of the refrigerator located in the lounge at the end of the 400 hallway. The surveyor was accompanied by the Dietary Manager. The refrigerator was locked. According to the Dietary Manager, the items in the refrigerator were used by the Activities Department staff for resident activities. Upon observation, the following items in the refrigerator had been opened but not dated when opened: - Bottle of Worcestershire sauce - Bottle of lemon juice - Bottle of peach flavored malt beverage - Tub of margarita salt The Dietary Manager confirmed these items in the 400 hall lounge refrigerator had not been dated when opened. She stated the items should have been dated when opened according to facility policy. The Dietary Manager discarded the items. On 05/15/18 at 1:00 PM, observations were made of the night pantry. The surveyor was accompanied by the Dietary Manager. The night pantry was in a locked room. According to the Dietary Manager, the refrigerator was used to obtain food for residents when the kitchen was not open. Food brought in by residents' families was also kept in the night pantry refrigerator. Upon observation, the following items located in a cupboard in the night pantry had been opened but not dated when opened: - Tub of peanut butter - Loaf of bread The Dietary Manager confirmed these items in the night pantry cupboard had not been dated when opened. She stated the items should have been dated when opened according to facility policy. The Dietary Manager discarded the items. On 05/15/18 at 1:10 PM, observations were made of the Activities Department refrigerator, located in the Activities Room adjacent to the dining room. The surveyor was accompanied by the Dietary Manager. According to the Dietary Manager, the food in the refrigerator was used by the Activities Department staff for resident activities. Upon observation, the following items located in the Activities Department refrigerator had been opened but not dated when opened: - Bag of sliced cheese - Bottle of sugar-free breakfast syrup - Bottle of light corn syrup - Bottle of chocolate syrup - Bottle of strawberry cocktail mix The Dietary Manager confirmed these items in the Activities Department refrigerator had not been dated when opened. She stated the items should have been dated when opened according to facility policy. The Dietary Manager discarded the items. Additionally, two (2) tubs of sour cream in the Activities Department refrigerator had a sell-by date of 4/23/18. The Dietary Manager stated facility policy was to discard items at the sell-by dates. She discarded the sour cream tubs.",2020-09-01
934,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2019-05-17,625,D,0,1,06KF11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to provide the second notice for the Bed Hold Policy to the resident representative via in writing or verbally within 24 hours of discharge to an acute care hospital. This was true for one (1) of three (3) residents reviewed for hospitalization s during the survey process. The resident representatives did not receive the Bed Hold notices timely in writing or verbally when R48 was transferred to the hospital. Resident identifiers: R48. Facility censes: 75. Findings included: a) R48 A medical record review for R48 on 05/13/19 revealed the second Bed Hold Notice had not been provided to the resident representative in writing or verbally within 24 hours when R48 was transferred to the hospital on [DATE]. In an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 05/13/19 at 10:30 AM verified R48's resident representative did not receive the second Bed Hold notice in writing or verbally when he was transferred to the hospital.,2020-09-01
935,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2019-05-17,656,D,0,1,06KF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to develop a care plan for a [MEDICAL TREATMENT] resident with interventions addressing complications related to [MEDICAL TREATMENT], pre and/or post [MEDICAL TREATMENT] assessments, blood pressure parameters, and post [MEDICAL TREATMENT] treatment care upon return to the facility from the [MEDICAL TREATMENT] center. This was true for one of one resident reviewed for [MEDICAL TREATMENT] services. This practice has the potential to affect a limited number of residents. Resident identifiers: R32 . Facility census: 75. Findings included: Review of records, on 05/14/19 at 09:39 AM, revealed Resident (R#32) brief interview for mental status (BIMS) score is fourteen (14) indicating resident is cognitively intact. The resident needs extensive to total assistance for activities of daily living. Some pertinent [DIAGNOSES REDACTED]. Records revealed R#32 regained their capacity to make medical decisions on 05/09/19. R#32 receives [MEDICAL TREATMENT] at an outpatient [MEDICAL TREATMENT] center three days a week. The orders showed Resident has [MEDICAL TREATMENT] on Monday, Wednesday, Friday at (name of [MEDICAL TREATMENT] center) at 12:00pm. (Name of ambulance service) to pick up at 11:30 a.m. An interview with the resident, on 05/14/19 at 09:39 AM, revealed the staff rarely ever takes her blood pressure or ask her anything specific when she returns to the facility from the [MEDICAL TREATMENT] center. R#32 said, They take my blood pressure in the mornings, most of the time. The residents stated the ambulance people that take her helps her back into the bed, and sometimes the nurse comes in and talks to the ambulance people. The resident said she comes back from the [MEDICAL TREATMENT] center with a dressing over her AV access and it is left on till the next day, and sometimes a nurse will look at it when she gets back from [MEDICAL TREATMENT]. An interview with licensed practical nurse (LPN#87), on 05/15/19 at 02:33 PM, revealed nursing staff does not do an assessment of Resident #32 when the resident returns to the facility from the [MEDICAL TREATMENT] center. LPN#87 stated, The ambulance crew returns the resident to her bed and I review the [MEDICAL TREATMENT] communication form to see if there's any new orders. LPN#87 said, If there is an area the [MEDICAL TREATMENT] center did not fill in on the form, like weights, I will call the center and get that information and fill in their part of the form or ask the ambulance crew. I do not document on the communications form any assessment of the resident when she returns back to the facility from the [MEDICAL TREATMENT] center. When asked why there was no post assessment documented, LPN#87 said, The nurses don't do a resident assessment when they return from [MEDICAL TREATMENT]. This surveyor asked if the nurses did any assessment of the resident's vital signs (VS - blood pressure, pulse, temperature, and respirations), the access site for bruits or thrills any swelling, drainage, or pain, or the resident's over all condition upon returning to the facility from the [MEDICAL TREATMENT] center. LPN#87 replied, The bruits are assessed only when scheduled and its document on the MAR (medication administration record) once every shift. No, the nurses don't assess that (bruits and thrills) when they return from the center On 05/15/19 at 03:39 PM review of R#32's care plan revealed [MEDICAL TREATMENT] interventions was addressed in the focus areas of Potential for fluid volume overload/deficit and Alteration in nutritional status. The focus area read Potential for fluid volume overload/deficit related to [MEDICAL CONDITION] requiring [MEDICAL TREATMENT], diuretic use for heart failure,-has port for [MEDICAL TREATMENT] at this time -12/18/18 [MEDICAL TREATMENT] shunt placed to left arm. The goal is Resident will maintain therapeutic fluid volume as evidenced by no fluid volume overload or deficit through next review date Care plan interventions for potential for fluid volume overload/deficit included: Administer diuretic orders as ordered. Check bruit and thrill q (every) shift and PRN (as needed) to left arm [MEDICAL TREATMENT] shunt. Report to MD (medical doctor) if absent. DermacinRx Prizopak Kit 2.5-2.5 % apply to Fistula (left arm) topically as needed for pain, apply 15 mins before [MEDICAL TREATMENT]. [MEDICAL TREATMENT] Monday, Wednesday, and Friday at 12:00 pm. STAT to pick up at 11:30 pm. No blood pressures or sticks to left arm d/t [MEDICAL TREATMENT] shunt. Notify physician of signs and symptoms of fluid volume overload or deficit such as [MEDICAL CONDITION], increased shortness of breath, increased confusion, fluid retention with decreased urinary output, increased cough and congestion, skin tenting, poor skin elasticity, increased thirst. Snack (NAS-No Added Salt) to be sent with resident on [MEDICAL TREATMENT] days Mon, Wed, and Friday. Some care plan interventions for alteration in nutritional status included: Diet as ordered for nutrition. NAS (No Added Salt) diet, Chopped Meats texture, Thin consistency No Orange Juice No Potatoes No Bananas No [NAME]toes. Obtain Labs per order notify MD of results and follow up as indicated. ProMod Liquid related to other Disorders of Plasma-Protein Metabolis. Report to nurse/MD of any signs or symptoms of dehydration such as dry crack lips and skin, poor skin turgor, elevated temp, rapid pulse. Snack bag- Monday, Wednesday, and Friday due to [MEDICAL TREATMENT]. Weights per orders, Notify MD of any significant changes. At 02:43 PM on 05/15/19, review of Resident #32's care plan and the [MEDICAL TREATMENT] communication record with the director of nursing (DON) revealed the care plan had no interventions noted concerning complications related to [MEDICAL TREATMENT]. It was the DON's expectations that residents receiving [MEDICAL TREATMENT] treatments have a pre and post assessment including vital signs before going out to the [MEDICAL TREATMENT] center, and immediately upon their return the facility following [MEDICAL TREATMENT] treatment. The DON confirmed the care plan did not offer directives for pre and/or post [MEDICAL TREATMENT] assessments of the resident, and should have, nor did it direct what to assess, when and how often to assess, nor parameters the facility desired for the vital signs of a [MEDICAL TREATMENT] resident.",2020-09-01
936,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2019-05-17,657,D,0,1,06KF11,"Based on medical record review, care plan review and staff interview, the facility failed to revise Resident #60's care plan to reflect the date of a pacemaker check had been rescheduled. This was found during a random review of the medical record for one of one reviewed for pacemaker care. Resident identifier: 60. Facility census: 75. Findings included: a) A review of the care plan in the medical record for resident #60 revealed the resident did have a pacemaker. The care plan showed a pace maker check was to be completed in April. There was no evidence that a pacemaker check had been done at that time. Discussion with the director of nursing on 5/15/19 in the afternoon verified that she could not find any documentation showing a pacemaker check. She then had nursing staff search for any information regarding the check. Nursing staff did submit evidence later that a pacemaker check had been completed in (MONTH) and at that time was rescheduled for six months which would be July. A new appointment was set for (MONTH) 26, 2019. The change in the appointment date was not changed on the care plan. The current care plan still stated pacemaker check for April, 2019.",2020-09-01
937,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2019-05-17,684,D,0,1,06KF11,"Based on observation, record review, resident interview, and staff interview the facility failed to ensure resident #74 received an accurate skin assessment reflecting the status of the resident's skin. This was true for one of one resident reviewed for skin conditions (non-pressure). This practice has the potential to affect a limited number of residents. Resident identifiers: R#74 . Facility census: 75. Findings included: a) Resident #74 Observations, on 05/13/19 at 3:35 PM, revealed R#74 had a noticeable asymmetric uneven black brownish area of discoloration, almost the size of a dime, with blurred irregular edges on his left cheek. The area on the resident's cheek had the appearance of a flat irregular mole. Also observed was a large area on the residence right lower forearm of faintly reddish pink discoloration. Review of records, on 05/16/19 at 09:58 AM, revealed neither areas were documented on any skin assessments. On 05/16/19 10:08 AM interview and review of records with Assistant Director of Nurses (ADON #50) revealed both skin areas were not documented on the nursing assessments, neither on the admission assessment or any following assessments as they should have been. The ADON acknowledged the areas were present on the resident and should be evaluated. ADON#50 requested the physician to evaluate the skin areas, as the physician was making rounds that day and resident is on list to be seen. An interview with the resident, on 05/16/19 at 10:55 AM, revealed he has always had the moles they had not newly developed but the one on his cheek had changed a little.",2020-09-01
938,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2019-05-17,698,D,0,1,06KF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview the facility failed to consistently perform pre and post [MEDICAL TREATMENT] resident assessments, before going and/or returning from the [MEDICAL TREATMENT] center. This was true for one of one resident reviewed for [MEDICAL TREATMENT] services. This practice has the potential to affect a limited number of residents. Resident identifiers: R32 . Facility census: 75. Findings included: a) Resident #32 Review of records, on 05/14/19 at 09:39 AM, revealed Resident (R#32) brief interview for mental status (BIMS) score is fourteen (14) indicating resident is cognitively intact. The resident needs extensive to total assistance for activities of daily living. Some pertinent [DIAGNOSES REDACTED]. Records revealed R#32 regained their capacity to make medical decisions on 05/09/19. R#32 receives [MEDICAL TREATMENT] at an outpatient [MEDICAL TREATMENT] center three days a week. The orders showed Resident has [MEDICAL TREATMENT] on Monday, Wednesday, Friday at (name of [MEDICAL TREATMENT] center) at 12:00pm. (Name of ambulance service) to pick up at 11:30 a.m. Review of the [MEDICAL TREATMENT] communication form, on 05/14/19 at 10:45 AM, show the following information was to be provided on the form by the facility before resident went for [MEDICAL TREATMENT] treatment: Resident's name; date; transported by; condition before leaving facility (Lines to write a narrative about the resident's condition); vital signs before [MEDICAL TREATMENT] (blood pressure, pulse, respirations, and temperature); received meal; and sent snack with resident. Information the [MEDICAL TREATMENT] center was to provide on the communication form was as follows: weight before; weight after; date of physicians visits at [MEDICAL TREATMENT]; labs drawn at [MEDICAL TREATMENT]; problems at [MEDICAL TREATMENT]; medications given; new orders; and vital signs before leaving [MEDICAL TREATMENT]. Review of the past month's [MEDICAL TREATMENT] communication sheets, starting 04/17/19 through 05/15/19, revealed on 04/17/19 the facility filled out the information except whether or not the resident received a meal. On 04/19/19 the facility did not send the [MEDICAL TREATMENT] center any information; the [MEDICAL TREATMENT] center however did send back to the facility a different communication sheet with their required information filled in. On 04/22/19 the facility filled out the information except whether the resident received a meal. On 04/24/19, 04/26/19, 04/29/19, 05/01/19, 05/06/19, 05/08/19, 05/10/19, and 05/13/19 only the resident's name; date; and vital signs were filled in. On 05/03/19 information missing on the form was the condition the resident was in before leaving the facility whether she received a meal or if a snack was sent with her. On 05/15/19 all information from the facility was completed. The [MEDICAL TREATMENT] communication form did not have a section for the resident's assessment upon return to the facility after [MEDICAL TREATMENT] treatment, as often seen on [MEDICAL TREATMENT] communication forms. Review of records, on 05/14/19 at 10:45 AM, revealed various nurse progress notes stating .resident is out at this time to [MEDICAL TREATMENT]. Resident clean, dry, and odor free. The few progress notes that mentioned the resident had returned to the facility, had information from the [MEDICAL TREATMENT] center placed in the note, but no notation or evidence of the facility nurse themselves assessing the resident. Example is a nursing note dated 05/10/19 .Vitals after [MEDICAL TREATMENT]: Blood pressure: 112/77, Pulse: 73, Reparations: 16, Temperature: 98.4, Weight: 115 kg per [MEDICAL TREATMENT] Communication form. An interview with the resident, on 05/14/19 at 09:39 AM, revealed the staff rarely if ever takes her blood pressure when she returns from [MEDICAL TREATMENT] treatment, or ever listens to her AV access with a stethoscope, or ask her anything specific when she returns to the facility from the [MEDICAL TREATMENT] center. R#32 said, They take my blood pressure in the mornings, most of the time. The residents stated the ambulance people that take her helps her back into the bed, and sometimes the nurse comes in and talks to the ambulance people. The resident said she comes back from the [MEDICAL TREATMENT] center with a dressing over her AV access and it is left on till the next day, and sometimes a nurse will look at it when she gets back from [MEDICAL TREATMENT]. On 05/15/19 at 01:25 PM review of orders revealed, [MEDICAL TREATMENT] Monday, Wednesday, and Friday at 12:00 PM. (Name of ambulance service) to pick up at 11:30 AM. No blood pressures or IV sticks to left arm due to fistula graft. Check bruit and thrill to left brachial [MEDICAL TREATMENT] fistula q (every) shift and prn (as needed). An interview with licensed practical nurse (LPN#87), on 05/15/19 at 02:33 PM, revealed nursing staff does not do an assessment of Resident #32 when the resident returns to the facility from the [MEDICAL TREATMENT] center. LPN#87 stated, The ambulance crew returns the resident to her bed and I review the [MEDICAL TREATMENT] communication form to see if there's any new orders. LPN#87 said, If there is an area the [MEDICAL TREATMENT] center did not fill in on the form, like weights, I will call the center and get that information and fill in their part of the form or ask the ambulance crew. I do not document on the communications form any assessment of the resident when she returns back to the facility from the [MEDICAL TREATMENT] center. When asked where the post [MEDICAL TREATMENT] assessment was documented, LPN#87 said, The nurses don't do a resident assessment when they return from [MEDICAL TREATMENT]. This surveyor asked if the nurses did any assessment of the resident's vital signs (VS - blood pressure, pulse, temperature, and respirations); access site for bruits or thrills any swelling, drainage, or pain; or the resident's over all condition upon returning to the facility from the [MEDICAL TREATMENT] center. LPN#87 replied, The bruits are assessed only when scheduled and its document on the MAR (medication administration record) once every shift. No, the nurses don't assess that (bruits and thrills) when they return from the center At 02:43 PM on 05/15/19, review of Resident #32's the [MEDICAL TREATMENT] communication record and care plan with the director of nursing (DON) revealed the [MEDICAL TREATMENT] communication record did not include an area to document a post [MEDICAL TREATMENT] assessment, the facility nurses should perform. It was the DON's expectations that residents receiving [MEDICAL TREATMENT] treatments have a pre and post assessment including vital signs before going out to the [MEDICAL TREATMENT] center, and upon their return the facility following [MEDICAL TREATMENT] treatment. When asked if the nurses did any assessment of the resident's vital signs (VS - blood pressure, pulse, temperature, and respirations); access site for bruits or thrills any swelling, drainage, or pain; or the resident's condition upon returning to the facility from the [MEDICAL TREATMENT] center, the DON confirmed they should be. When asked where the nurses should be documenting their assessment of the resident when returning from [MEDICAL TREATMENT] treatments the DON said it should be at least in the nurses' progress note. The DON said, The bruit and thrill is done every shift and is documented on the MAR. The DON confirmed the order for checking the bruit and thrill PRN (as needed) would be when the resident had a problem or when they returned from [MEDICAL TREATMENT]. This surveyor requested any evidence that any post [MEDICAL TREATMENT] treatment assessments were being done by the facility when the resident return to the facility from the [MEDICAL TREATMENT] center, upon exit no evidence was provided.",2020-09-01
939,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2019-05-17,812,E,0,1,06KF11,"Based on observation and staff interviews, the facility failed to ensure foods were handled in a manner that promoted safe sanitation techniques. Foods were found stored incorrectly, and staff used the same gloves to handle food and non-food items This practice has the potential to affect more than a limited number of residents who are served from this central location. Facility census: 75. Findings included:a) During the initial tour of the dietary department at 11:00 a.m on 5/13/19 at lunch revealed the following issues. The dietary manager was present at the time of the observations. 1. Sugar was stored with the scoop being in direct contact with the product. Scoops are to be stored in a manner that the serving portion is not in contact with the product. 2. A styrofoam cup was stored directly in a plastic container in the product. The dietary manager identified it as thickened. This also should have the device used to scoop the item from the container not be in direct contact with the product itself. 3 A dietary staff member was noted to be handling fried green tomatoes with her gloved hand. The staff was also seen touching non-food items with those same gloves. This practice could lead to possible cross contamination of the foods.",2020-09-01
940,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2019-05-17,923,E,0,1,06KF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, resident family interview, and staff interview the facility failed to ensure adequate ventilation in a communal resident television lounge room, adjoining hallways, and in nearby resident's room as evidenced by the strong cigarette smoke odor lingering in the facility during and after the resident's smoke breaks. This practice has the potential to affect more than a limited number of residents and more than a limited area is affected. Resident identifiers: R#14 and R#28. Facility census: 75. Findings included: a) Resident #14 and #28 On 05/13/19 at 11:22 AM, this surveyor was walking in the hallway between the two nurses' stations, when encountering an overwhelming strong smell of cigarette smoke. The Assistant Director of Nurses (ADON #50) appeared in the hallway coming from the communal television, the surveyor asked ADON #50 if they allowed the residents to smoke inside the building. ADON #50 replied, No they have to go outside to smoke. Looking through the television lounge doorway, observations revealed three (3) residents in wheelchairs right outside the door smoking in the courtyard and two (2) more residents in wheelchairs in the television lounge opening the door trying to go through the doorway to the outside. Interview with Resident (R#28)'s daughter, on 05/13/19 at 11:26 AM, revealed during the interview the daughter requested to stop the interview long enough for her to get up and close the resident's door to the room. The daughter stated, It must be time for the smokers to start smoking, the only way we can deal with it is if I close the door and turn on the exhaust fan in the bathroom. It helps some. The daughter said the facility took good care of her mother the only issue she has is the smoke smell that comes into the room. When asked if she ever told anyone about the smoke smell, the daughter stated it's been a while ago when a maintenance man came in the room change a filter in the heating system. I asked him about an air purifier because of the smoke smell, but I did not follow up on it, and that's been a while ago. The daughter was not sure of the maintenance man's name. The daughter also stated the smoke smell really bothers her mother's roommate. On 05/16/19 at 11:52 AM, review of Resident (R#28) records revealed one of the resident's [DIAGNOSES REDACTED]. On 05/13/19 at 02:58 PM, an interview with Resident (R#14) revealed the resident can smell smoke in her room. R#14 said, It gives me a migraine. I don't smoke. When asked R#14 said she told staff about the smoke smell but could not give a name of the staff she told. Multiple observations throughout the survey revealed residents that smoke, travel through the communal television lounge room to the exit door that opens to the outside courtyard. The designated smoking area is in the courtyard right outside the communal television lounge room's door. The communal television lounge room can be used both by smokers and non-smokers. The communal television lounge room smells of cigarette smoke even when no one is outside smoking or anyone's in the room. Cigarette smoke at times was so heavy it can be smelled at both nursing stations on either end of the hallway that was outside of the communal Television lounge. This surveyor requested the director of nursing (DON) to take a stroll with this surveyor down the hallway outside the communal television lounge, on 05/15/19 at 11:55 AM. The DON strolled with this surveyor and confirmed the smoke smell was strong and agreed the facility needed better ventilation in that area. The DON said she would see that it was addressed.",2020-09-01
4786,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2016-01-20,223,D,0,1,V5RK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, staff interview, Centers for Disease Control and Prevention interview, State Epidemiology interview, and policy review the facility did not ensure one (1) of nine (9) residents, reviewed for abuse allegations in Stage 2 of the quality indicator survey (QIS), was free of abuse. Resident #14 was involuntarily secluded due to a history of a multi-drug resistant organism. Resident identifier: #14. Facility census: 81. Findings include: a) Resident #14 During a Stage 1 interview, on 01/11/16 at 12:55 p.m., Resident #14 related he only participated in activities in his room. The resident related he was told he had an infection and could not go outside of his room for activities. A physician's orders [REDACTED]. Review of the care plan, on 01/12/16, at 4:00 p.m. revealed a focus, initiated on 06/19/14 related to isolation precautions due to Resident #14 had a history of [REDACTED]. Interventions indicated gloves would be worn upon entry of the room, and other PPE (personal protective equipment) would only be required if substantial contact with resident expected. The Carbapenem Resistant [MEDICATION NAME] (CRE) policy, reviewed on 01/12/16 at 2:59 p.m., revealed the purpose was to prevent transmission ., and to ensure compliance with federal and state regulations .according to centers for disease control (CDC) guidelines. The policy also indicated isolation would be discontinued after completion of antibiotic therapy, then in thirty (30) days if three (3) consecutive cultures obtained from the source of infection were negative, unless otherwise advised the isolation would remain discontinued. An interview with the infection control preventionist, Licensed Practical Nurse (LPN #106), on 01/13/16 at 10:02 a.m., revealed she utilized the CRE toolkit and the CDC had been contacted when Resident #14 was admitted to the facility. The nurse related one infectious disease specialist indicated the resident should be kept in isolation indefinitely; and the other specialist indicated the resident could be removed from isolation in (MONTH) of (YEAR). LPN #106 related Resident #14 would sometimes have a home pass, had a catheter, and knew how to wash his hands. She related the medical director did not feel comfortable allowing the resident out of his room, and had continued contact precautions, including segregation from other residents. LPN #106 related Resident #14 had acquired CRE prior to admission, and contact precautions were implemented immediately, LPN #106 said the resident had never been out of isolation, since admission on 06/17/2014. The nurse related the infectious disease specialist was contacted and had told the facility, There was no reason for the resident to return to his office. Progress notes, reviewed from admission to current, revealed the following notes: -06/19/14 .Contact isolation precautions continue d/t (due to) CRE in urine . New orders to schedule appointment with infectious disease specialist for further treatment instructions of CRE. Resident to remain in isolation until cleared by the infectious disease doctor per the medical director. -07/14/14 progress note indicated the resident was out of facility with EMS (emergency medical service) to an appointment with Infectious Disease Specialist #1 (IDS#1). The resident returned to the facility with an order for [REDACTED].#1. -07/16/14 progress note indicated the physician had spoken with IDS#1 and the specialist had recommended the resident remain in isolation while in the facility due to his history of CRE, VRE and [MEDICAL CONDITION]. -07/30/14 progress note indicated Resident #14 attended an appointment scheduled with IDS#2 for a second opinion, and indicated IDS#2 recommended the resident continue contact isolation for six (6) more months. -08/05/14 note indicated the LPN #106 contacted the CDC for recommendations, to no fruition, and a note dated 08/06/14 indicated the facility received an email from the CDC noting, No recommendation can be made regarding when to discontinue contact precautions. -11/14/14 a physician's orders [REDACTED]. -01/23/15 a health status note indicated Resident #14 had an appointment with IDS#2, who recommended the resident remain in isolation until (MONTH) (YEAR), and follow up as needed. -03/25/15 plan of care note indicated the social worker was to monitor Resident #14's adjustment to being placed in isolation and not having enough social contact. Resident will remain in isolation until 06/01/15. -06/17/15 nursing note indicated the facility physician was notified of the IDS#2 recommendation for the resident to be removed from isolation, but the facility physician related he decided to go with IDS#1 .and leave the resident in isolation indefinitely. Urinalysis with culture and sensitivity, obtained on 08/31/15, 11/25/15, and 12/18/15 failed to isolate CRE and/or noted No CRE or VRE isolated. Review of the Facility Guidance for Control of Carbapenem-resistant [MEDICATION NAME] (CRE) (MONTH) (YEAR) Update - CRE Toolkit, indicated, residents with CRE at lower risk for transmission .do not need to be restricted from common gatherings in the facility (e.g. meals, group activities .) An observation and interview, on 01/20/2016 at 8:46:55 AM, with Resident #14 revealed the resident lying in bed, supine position, watching television. A cart was placed outside the door of the room and contained, gowns, gloves, booties, hairnets, upon inquiry as to how the resident felt about staying in his room, he related he sometime left his room in the evenings when no one else was in the hallway but not very often. Related he could not go out anytime he wanted. He said he did get showers. Resident #14 said it made him, feel bad that he could not go out of his room during times of activities. Further inquiry revealed the resident did not touch his catheter and knew how to wash his hands. An interview with Nurse Aide #27(NA) on 01/201/6 at 8:49 a.m., revealed the resident left his room, once in a while, late at night. The NA indicated the resident used to go outside when no one else was out there, but did not believe he had been out since summer, and said activities were done in his room. The NA related the catheter seldom leaked and the resident knew how to wash his hands. She further added, He is very good at that. An interview with the centers for disease control, on 01/20/16 at 10:42 a.m., indicated residents who were colonized with CRE, and were low risk for transmission, required standard precautions. Upon inquiry, the CDC consultant related it was not necessary for the resident to be confined to his room and referred to CDC guidelines for multi-drug resistant organisms. The consultant also suggested guidance from the state health department for more stringent guidelines imposed by state regulations. An interview with the epidemiologist, on 01/20/16 at 11:16 a.m., also revealed the resident did not require segregation from other residents. He related as long as the resident was negative for CRE, and the secretions were contained, he should not be isolated from other residents. Upon inquiry as to incontinence, the epidemiologist related, if the stool was contained in the brief, the resident should be able to leave his room. Further inquiry revealed a stool culture was not necessary. Another interview with the infection control preventionist, and the administrator, on 01/20/16 at 11:52 a.m., again revealed LPN #106 had referred Resident #14 to the physician/medical director in (MONTH) (YEAR), requesting the resident be allowed to leave his room, but the doctor did not feel comfortable. She again related IDS#1 had indicated the resident remain in isolation indefinitely and IDS#2 had related the isolation could be stopped in six to twelve (6-12) months, which ended (MONTH) (YEAR). LPN #106 related the physician was notified of ongoing negative urine cultures, which the physician had reviewed and signed. Upon inquiry, the LPN related the resident had no un-contained fluids. She related the resident utilized a catheter for urine and a brief for stool. An interview with the physician/medical director, on 01/20/16 at 11:58 a.m., confirmed he had not contacted IDS#1 after the urine cultures returned negative. The physician related the specialist had previously related, Not enough was known about the disease, and related the resident should remain isolated indefinitely. Upon inquiry, the physician related he had not reviewed the (MONTH) (YEAR) CRE update provided by the CDC, and would confer with specialists again.",2019-07-01
4787,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2016-01-20,225,F,0,1,V5RK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, medical record review, policy review, reive of personnel records, and the Affordable Care Act, the facility failed to ensuer they screened one (1) of ten (10) employees by not ensuring they completed crominal background checks. Additionally, they failed to throughly investigate and report allegations of abuse/neglect for three 93) of nine (9) residents reviewed for abuse and neglect. These practices had the potential to affect all residents in the facility. Resident identifiers: Resident #48, #77, and #106. Facility census: 81. Findings include: a) Resident #48 During a Stage 1 interview, on 01/19/16 at 11:53 a.m., Resident #48 related that he felt like staff did not want to come to his room at times. He related he believed he had been vervbally abused. The resident related the incidents occurred more than once over the past couple of months. Resident #48 also related he felt like some of the staff got rough with him, because they had to provide care for him. Additionall, the resident related he had been left in urine and poop and not enough staff was available. He related the licensed practice nurses or registered nurses would answer the call bell, but would not provide care, and he had to wait for thirty 930) minutes. He further added, It gets old. The resident related he told the supervisor. Upon inquiry, Resident #48 related he told Social Worker (SW #76). The minimum datea set (MDS) with an assessment reference date (ARD) of 10/20/15, reviewed on 01/14/5 at 8:08 a.m., revealed a brief interview for mental status (BIMS) score of 14, indicating Resident #48 was cognitively intact. The highest attainable score was 15. Further review revealed he was totally dependent upon staff for bed mobility, transfer, toileting, personal hygiene and bathing. Concern/complaint/grievance forms, and reportable allegations, reviewed on 01/13/15, revealed no evidence the facaility had filed/reported an allegation of neglect on Resident #48's behalf. During an inteview with SW #76 on 01/19/16 at 11:53 a.m., she related Resident #48 often called her into his room as she was walking down the hall. The SW said, the resident complained that his alarm would go off and he said he waited for someone to answer the alarm. She related resident told her he felt like staff did not want to come in there at times. SW #76 related the resident dold her he had been left in urine and feces, but denied neglect, and did not want it reported. She related, I told him, now you know I hace to report this, are you sure? The social worker related she would review tapes and interview staff. On 01/19/16 at 2:45 p.m., another interview with SW #76 revealed she tried to determine what actually happened prior to reporting incidents. The social worker related if a concern/complaint/allegation was made, she would say to the staff, This is what I was told and try to determine what actually occurred, and if deemed reportable, would report it. During an interview with Resident #48, on 01/20/16 at 8:35 a.m., the resident related the social worker had not visited him this week (Monday, Tuesday or Wednesday). He related he was not notified of the outcome of the concerns/allegations he had reported. Additionally, the resident related he did not know how to report to the appropriate state agencies, only the facility staff. A follow-up inteview with SW #76 on 01/20/16 at 3:30 p.m., confirmed no reports had been filed related to Resident #48's allegations, and the SW was unable to provide evidence the allegations were investigated. b) Residen #77 A review of reportable allegations, on 01/13/16 at 3:30 p.m., revealed a noted dated 11/21/15 at 7:14 p.m., and signed by the Licensed Practical Nurse (LPN) #93. The report indicated a family member had reported to LPN #101 that Resident #77 was out of the facility. Staff immediately contacted (local) Police Department and began searching in and out of the facility. LPN #95 and minimum data set (MDS) Nurse #78 reviewed the cameras, which indicated the resident was last seen walking toward the water tower and up the hill behind the facility at 11:24 a.m. Inspection of the courtyard revealed knee prints, and wires that were holding the fencing to the pole together were untwisted. The physical area was fixed to prevent further elopement. The report did not indicate what time the resident was reported as missing, nor did it provide any inforamtion regarding staffs lack of awareness that the resident was missing. The Immediate Fax reporting of allegation form indicated the time of the incident as 11:24 a.m. on the 440-hall west side courtyard. The reports indicated a search was inside and outside of the facility, and was found about one (1) mile away, heading back towards the facility. The form did not indicate the time the search was initiated, nor the time the resident was found. An interview with Licensed Practical Nurse #93 (LPN), on 01/13/16 at 3:59 p.m., revealed Resident #77 had eloped under the fence in the courtyard near the administrator's office. The LPN related another nurse had called and related someone had seen the resident and the facility transported him back. When asked how the facility identified how the resident eloped, the LPN related staff had watched the cameras. LPN #77 related she could not remember whether staff completed witness statements related to the event. LPN #93 related the 911 emergency lines, and the police were called to make sure the resident was safely found. LPN #93 reviewed the medical record and confirmed the record did not indicate at what time the resident was reported missing. nor the time of his return. She related she could not remember. Further inquiry, revealed she was the unit charge nurse at the time of the incident. The LPN related staff had not reported an inability to locate the resident prior to the family notifiying the facility. LPN #93 related she was unaware of any follow-up intervention related to staff oversight of residents. The nurse indicated staff had not reported the resident as unavailable during smoke breaks or for lunch. An interview with the 911 center, on 01/19/16 at 1:29 p.m., revealed the facility called in the elopement at 15:06 (3:06) p.m. on 11/21/15. Upon inquiry as to who completed the investigation, LPN #93 related she believed the social worker was responsible. Additionally, interviews, with the Activity Director (AD) on 01/12/16 at 2:42 p.m. and Registered nurse #18 (RN), on 01/13/16 at 9:50 a.m., also related the social worker completed investigation of abuse and neglect when she returned to work. On 01/13/16 at 8:40 a.m., review of the abuse and neglect policy. located in a binder at the nurses' station, revealed the chain of command reported to the immediate supervisor, and the facility would take whatever measures were necessary to protect the victim. It indicated the facility would review the work schedule and identify staff who had worked up to 72 hours prior to the event and each employee would be questioned individually. A form indicating the date, time reported, response and description of abuse was to be placed under the door of the social worker or administrator. An interview with Social Worker #76 (SW), indicated the incident occurred on a weekend. She relaled the director of nursing would have been notified first, and a registered nurse supervisor (RN #18) was present and informed her. She further related the facility fixed the areas right then and there. The SW related the fence was relatively new and had been built as a non-smoking area. During another interview with SW #76, on 01/14/16 at 9:29 a.m., the SW related the facility was not aware Resident #77 had been a flight risk. She did relate, however, the resident had blamed her and said she was keeping him hostage at the facility. SW#76 reviewed the reportable allegation and related she believed the resident returned to the facility earlier than the note, which was dated and times as 11/21/15 at 7:14 p.m. When asked how long the resident had been missing prior to staff's awareness. the social worker related she did not know. Further review of the medical record, on 01/14/16 at 9:51 a.m., revealed [DIAGNOSES REDACTED]. [MEDICAL CONDITION] (dizziness), diabetes mellitus, hypertension, and [MEDICAL CONDITION]. The brief interview for mental status (SIMS) score was eleven (11) which indicated cognitive impairment. The immediate five (5) day follow-up completed by SW #76 noted, Resident was/did elope from facility while staff not watching. Resident was found by staff and brought back to the facility safe with only minor redness and scrapes . The social worker confirmed no evidence was present to indicate staff had been interviewed, or the incident had been thoroughly investigated to ensure the resident had been adequately supervised at the time of the elopement. c) Resident #106 Review of concerns and grievances, on 01/18/15 revealed an allegation dated 11 123f15 by Licensed Practical Nurse #107 (LPN) which indicated a responsible party had called the facility on 11/22/15 alleging abuse of Resident #106. The allegation indicated Resident #106 had not received her medication ([MEDICATION NAME]) and was treated for [REDACTED]. The hospital told me she was overdosed, and you shouldn't (should not) be asking me if she's (she is) confused you should do your job and read through her chart A note. dated 11/23/15 indicated Assistant Director of Nursing #34 (ADON) had called the daughter to request a meeting. No evidence was present to indicate the allegation of abuse had been reported to the approoriate state agencies. An interview, with Social Worker #76 (SW) confirmed the event had not been reported to state agencies. She related the director of nursing (DON) had handled it, and that she had not reviewed it. d) Criminal background checks The Affordable Care Act and West Virginia Code Chapter 16, Article 49 required direct access employees of nursing facilities, at a minimum, to complete a State and Federal fingerprint-based criminal investigation background checks prior to hire. Personnel records. reviewed on 01/13/16 at 1:52 p.m. with Medical Records #70 (MR) revealed no evidence the facility completed a State and Federal criminal background check for Physical Therapist #108 (PT), prior to hire on 10/15/15. On 01/13/16 at 2:55 p.m., a review of the time sheet, on 3116 at 2:55 p.m., confirmed PT #108 had worked on 11/27/15, 12/19/15, 12/24/15, and 01/01/16. An interview with the administrator on 01/ at 3:20 p.m. revealed the contracted company was responsible for completing criminal background checks, and confirmed a fingerprint background check had not been completed. A review of the facility policy revealed the following in regards to screening employees: In order to protect all residents. during the hiring process a newly hired employee will be screened. This will be accomplished through the local law enforcement, state police and other agencies. Once the checks have been completed and show no evidence of abuse or neglect the emr:loyee will then be fingerprinted and a background check is then initiated. The employee will be allowed to work until the background check comes back to facility. If the report is unfavorable, the individual will be terminated immediately.",2019-07-01
4788,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2016-01-20,226,F,0,1,V5RK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, medical record review, policy review and review of the Affordable Care Act (ACA) guidelines, the facility failed to operationalize abuse/neglect policies and procedures for screening, training, identification, prevention, and investigating allegations of abuse and neglect for three (3) of nine (9) residents reviewed. The facility failed to thoroughly investigate allegations of neglect for Resident #77. The facility failed to identify an allegation of neglect and protect a resident after an allegation of neglect was made by Resident #48. The facility failed to ensure Resident #14 was free from abuse. Resident #14 was involuntarily secluded from other residents and activities. The facility failed to report an allegation of neglect to State agencies for Resident #106. In addition, they failed to operationalize screening policies and procedures to ensure completion of a fingerprint based criminal background check for one (1) of ten (10) employee personnel files reviewed. These practices had the potential to affect all residents in the facility. Resident identifiers: Resident #14, #48, #77, and #106. Facility census: 81. Findings include: a) Resident #48 During a Stage 1 interview, on 01/19/16 at 11:53 a.m., Resident #48 related he felt like staff did not want to come to his room at times. He related he believed he had been verbally abused. The resident said the incidents occurred more than once over the past couple of months. Resident #48 also related he felt like some of the staff got rough with him, because they had to provide care for him. Additionally, the resident related he had been left in urine and poop and not enough staff was available. He related the licensed practical nurses or registered nurses would answer the call bell, but would not provide care, and he had to wait for thirty (30) minutes. He further added, It gets old. The resident related he told the supervisor. Upon inquiry, Resident #48 related he told Social Worker (SW) #76. The minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/20/15, reviewed of 01/14/15 at 8:08 a.m., revealed a brief interview for mental status (BIMS) score of 14, indicating Resident #48 was cognitively intact. The highest attainable score was 15. Further review revealed he was totally dependent upon staff for bed mobility, transfer, toileting, personal hygiene and bathing. Concern/complaint/grievance forms, and reportable allegations, reviewed on 01/13/15, revealed no evidence the facility had filed a concern or allegation on Resident #48's behalf. During an interview with SW #76 on 01/19/16 at 11:53 a.m., she related Resident #48 often called her into his room as she was walking down the hall. The SW said the resident complained that his alarm would go off and he would have to wait for a long time. She related the resident told her he felt like staff did not want to come in there at times. SW #76 related the resident told her he had been left in urine and feces, but denied neglect, and did not want it reported. She related, I told him, now you know I have to report this, are you sure? The social worker related she would review tapes and interview staff. On 01/19/2016 2:45 p.m., another interview with SW#76, revealed the SW tried to determine what actually happened with an incident prior to reporting the incidents. SW #76 related if a concern/complaint/allegation was made, she would say to the staff, This is what I was told and then she would try to determine what actually occurred, and if she deemed it reportable, she would report it. During an interview with Resident #48, on 01/20/16 at 8:35 a.m., the resident related the social worker had not visited him this week (Monday, Tuesday or Wednesday.) He related he was not notified of the outcome of the concerns/allegations he had reported. A follow-up interview with SW #76 on 01/20/16 at 3:30 p.m., confirmed no reports had been filed related to Resident #48's concerns, and was unable to provide evidence the concerns had been investigated. A review of a reportable allegation, on 01/13/16 at 3:20 p.m., revealed a note dated 11/21/15 at 7:14 p.m., and signed by Licensed Practical Nurse (LPN) #93. The report indicated a family member had reported to LPN #101 that Resident #77 was out of the facility. Staff immediately contacted (local) Police Dept. and began searching in and out of the facility. LPN #95 and minimum data set (MDS) Nurse #78 reviewed the cameras, which indicated the resident was last seen walking toward the water tower and up the hill behind the nursing home at 11:24 a.m. Inspection of the courtyard revealed knee prints, and wires that were holding the fencing together to the pole were untwisted. The physical area was fixed to prevent further elopement. The report did not indicate what time the resident was reported as missing, nor staffs lack of awareness the resident was missing. The immediate fax reporting of allegation form indicated the time of the incident as 11:24 a.m. on the 400-hall west side courtyard. The reports indicated a search was initiated in side and out-side of the facility, and was found about one (1) mile away, heading back towards the facility. The form did not indicate the time the search was initiated, not the time the resident was found. An interview with Licensed Practical Nurse #93 (LPN), on 01/13/16 at 3:59 p.m., revealed Resident #77 had eloped under the fence in the courtyard near the administrator's office. The LPN related another nurse had called and related someone had seen the resident, and the facility transported him back. When asked how the facility identified how the resident eloped, the LPN related staff had watched the cameras. LPN #77 related she could not remember whether staff completed witness statements related to the event. LPN #93 related the 911 emergency line, and the police were called to make sure the resident was safely found. LPN #93 reviewed the medical record and confirmed the record did not indicate at what time the resident was reported missing, nor the time of his return. She related she could not remember. Further inquiry, revealed she was the unit charge nurse at the time of the incident. The LPN related staff had not reported an inability to locate the resident prior to the family notifying the facility. LPN #93 related she was unaware of any follow-up intervention related to staff oversight of residents. The nurse indicated staff had not reported the resident as unavailable during smoke breaks or for lunch. An interview with the 911 center, on 01/19/16 at 1:29 p.m., revealed the facility called in the elopement at 15:06 (3:06) p.m. on 11/21/15. Upon inquiry as to who completed the investigation, LPN #93 related she believed the social worker was responsible. Additionally, interviews, with the Activity Director (AD) on 01/12/16 at 2:42 p.m. and Registered nurse #18 (RN), on 01/13/16 at 9:50 a.m., also revealed the social worker completed investigation of abuse and neglect when she returned to work. On 01/13/16 at 8:40 a.m., review of the abuse and neglect policy, located in a binder at the nurses ' station, revealed the chain of command was to report to the immediate supervisor, and the facility would take whatever measures were necessary to protect the victim. It indicated the facility would review the work schedule and identify staff who had worked up to 72 hours prior to the event and each employee would be questioned individually. A form indicating the date, time reported, response and description of abuse was to be placed under the door of the social worker or administrator. An interview with Social Worker #76 (SW), indicated the incident occurred on a weekend. She related the director of nursing would have been notified first, and a registered nurse supervisor (RN #18) was present and informed her. She further related the facility fixed the areas right then and there. The SW related the fence was relatively new and was built as a non-smoking area. During another interview with SW #76, on 01//14/16 at 9:29 a.m., the SW related the facility was not aware Resident #77 had been a flight risk. She did relate, however, the resident had blamed her and said she was keeping him hostage at the facility. SW#76 reviewed the reportable allegation and related she believed the resident returned to the facility earlier than the note, which was dated and times as 11/21/15 at 7:14 p.m. When asked how long the resident had been missing prior to staff's awareness, the social worker related she did not know. Further review of the medical record, on 01/14/16 at 9:51 a.m., revealed [DIAGNOSES REDACTED]. The brief interview for mental status (BIMS) score was eleven (11) which indicated cognitive impairment. The immediate five (5) day follow-up completed by SW #76 noted, Resident was/did elope from facility while staff not watching. Resident was found by staff and brought back to the facility safe with only minor redness and scrapes . The social worker confirmed no evidence was present to indicate staff were interviewed, or the incident had been thoroughly investigated to ensure the resident had been adequately supervised at the time of the elopement. c) Resident #14 During a stage one interview, on 01/11/16 at 12:55 p.m., Resident #14 related he only participated in his rooms. The resident related he was told he had an infection and could not go outside of his room for activities. The carbapenem resistant [MEDICATION NAME] (CRE) policy, reviewed on 01/12/16 at 2:59 p.m., revealed the purpose was to prevent transmission ., and to ensure compliance with federal and state regulations .according to centers for disease control (CDC) guidelines. The policy also indicated isolation would be discontinued after completion of antibiotic therapy, then in thirty (30) days, three (3) consecutive cultures obtained from the source of infection and results were negative, unless otherwise advised. A physician's orders summary, dated 12/29/15, reviewed on 01/12/16 at 3:30 p.m., revealed an order for [REDACTED]. Review of the care plan, on 01/12/16, at 4:00 p.m. revealed a focus, initiated on 06/19/14 related to isolation precautions due to Resident #14 had a history of [REDACTED]. Interventions indicated gloves would be worn upon entry of the room, and other PPE would only be required if substantial contact with resident expected. An interview with the infection control preventionist, Licensed Practical Nurse (LPN #106), on 01/13/16 at 10:02 a.m., revealed she utilized the CRE toolkit and the CDC had been contacted when Resident #14 was admitted to the facility. The nurse related one infectious disease specialist indicated the resident should be kept in isolation indefinitely; and the other specialist indicated the resident could be removed from isolation in (MONTH) of (YEAR). LPN #106 related Resident #14 would sometimes have a home pass, had a catheter, and knew how to wash his hands. She related the medical director did not feel comfortable allowing the resident out of his room, and had continued contact precautions, including segregation from other residents. LPN #106 related Resident #14 had acquired CRE prior to admission, and contact precautions were implemented immediately, and had never been out of isolation, since admission on 06/17/2014. The nurse related the infectious disease specialist was contacted and had told the facility, There was no reason for the resident to return to his office. Progress notes, reviewed from admission to current, revealed notes dated: --06/19/14, which indicated .Contact isolation precautions continue d/t (due to) CRE in urine .New orders to schedule appointment with infectious disease specialist for further treatment instructions of CRE. Resident to remain in isolation until cleared by the infectious disease doctor per the medical director. --07/14/14 progress note indicated the resident was out of facility with EMS (emergency medical service) to an appointment with Infectious Disease Specialist #1 (IDS#1). The resident returned to the facility with an order for [REDACTED].#1. --07/16/14 progress note indicated the physician had spoken with IDS#1 and the specialist had recommended the resident remain in isolation while in the facility due to his history of CRE, VRE and [MEDICAL CONDITION]. --07/30/14 progress note indicated Resident #14 attended an appointment scheduled with IDS#2 for a second opinion, and indicated IDS#2 recommended the resident continue contact isolation for six (6) more months. --08/05/14 note indicated the LPN #106 contacted the CDC for recommendations, to no fruition, and a note dated 08/06/14 indicated the facility received an email from the CDC noting, No recommendation can be made regarding when to discontinue contact precautions. --11/14/14 physician's order note indicated a urine culture and sensitivity (C&S) result indicated, No VRE,[MEDICAL CONDITION] or CRE identified. --01/23/15 health status note indicated Resident #14 had an appointment with IDS#2, who recommended the resident remain in isolation until (MONTH) (YEAR) and follow up as needed. --03/25/15 - a plan of care note indicated the social worker was to monitor Resident #14's adjustment to being placed in isolation and not having enough social contact. Resident will remain in isolation until 06/01/15. --06/17/15 nursing note indicated the facility physician was notified of the IDS#2 recommendation for the resident to be removed from isolation, but the facility physician related he decided to go with IDS#1 .and leave the resident in isolation indefinitely. Urinalysis with culture and sensitivity, obtained on 08/31/15, 11/25/15, and 12/18/15 failed to isolate CRE and/or noted No CRE or VRE isolated. Review of the Facility Guidance for Control of Carbapenem-resistant [MEDICATION NAME] (CRE) (MONTH) (YEAR) Update - CRE Toolkit, indicated, residents with CRE at lower risk for transmission .do not need to be restricted from common gatherings in the facility (e.g. meals, group activities .) An observation and interview, on 01/20/2016 at 8:46:55 AM, with Resident #14 revealed the resident lying in bed, supine position, watching television. A cart was placed outside the door of the room and contained, gowns, gloves, booties, hairnets, upon inquiry as to how the resident felt about staying in his room, he related he sometime left his room in the evenings when no one else was in the hallway - not very often. Related he could not go out anytime he wanted, but did get showers. Resident #14 said it made him, feel bad that he could no go out of his room during times of activities. Further inquiry revealed the resident did not touch his catheter and knew how to wash his hands. An interview with Nurse Aide #27(NA) on 01/201/6 at 8:49 a.m., revealed the resident left his room, once in a while, late at night. The NA indicated the resident used to go outside when no one else was out there, but did not believe he had been out since summer, and said activities were done in his room. The NA related the catheter seldom leaked and the resident knew how to wash his hands. She further added, He is very good at that. An interview with the centers for disease control, on 01/20/16 at 10:42 a.m., indicated residents who were colonized with CRE, and were low risk for transmission, required standard precautions. Upon inquiry, the CDC consultant related it was not necessary for the resident to be confined to his room and referred to CDC guidelines for multi-drug resistant organisms. The consultant also suggested guidance from the state health department for more stringent guidelines imposed by state regulations. An interview with the epidemiologist, on 01/20/16 at 11:16 a.m., also revealed the resident did not require segregation from other residents. He related as long as the resident was negative for CRE, and the secretions were contained, he should not be isolated from other residents. Upon inquiry as to incontinence, the epidemiologist related, if the stool was contained in the brief, the resident should be able to leave his room. Further inquiry revealed a stool culture was not necessary. Another interview with the infection control preventionist, and the administrator, on 01/20/16 at 11:52 a.m., again revealed LPN #106 had referred the Resident #14 to the physician/medical director in (MONTH) (YEAR), requesting the resident be allowed to leave his room, but the doctor did not feel comfortable. She again related IDS#1 had indicated the resident remain in isolation indefinitely and IDS#2 had related the isolation could be stopped in six to twelve (6-12) months, which ended (MONTH) (YEAR). LPN #106 related the doctor had been notified of ongoing negative urine cultures, which the physician had reviewed and signed. Upon inquiry, the LPN related the resident had no un-contained fluids. She related the resident utilized a catheter for urine and a brief for stool. An interview with the physician/medical director, on 01/20/16 at 11:58 a.m., confirmed he had not contacted IDS#1 after the urine cultures returned negative. The physician related the specialist had previously related, Not enough was known about the disease, and related the resident should remain isolated indefinitely. Upon inquiry, the physician related he had not reviewed the (MONTH) (YEAR) CRE update provided by the CDC, and would confer with specialists again. The abuse and neglect policy reviewed on 01/14/16, indicated prevention of abuse was accomplished through education of residents and families as to what constituted abuse and monitor to assure those policies and procedures were implemented. Lastly, the policy noted, One major item to keep in mind during the investigation is to keep the resident protected from any further harm until the problem has been resolved. d) Resident #106 Review of concerns and grievances, on 01/18/15 revealed an allegation dated 11/23/15 by Licensed Practical Nurse #107 (LPN) which indicated a responsible party had called the facility on 11/22/15 alleging abuse of Resident #106. The allegation indicated Resident #106 had not received her medication ([MEDICATION NAME]) and was treated for [REDACTED]. The hospital told me she was overdosed, and you shouldn't (should not) be asking me if she's (she is) confused you should do your job and read through her chart A note, dated 11/23/15 indicated Assistant Director of Nursing #34 (ADON) had called the daughter to request a meeting. No evidence was present to indicate the allegation of abuse had been reported to the appropriate State agencies. An interview with Social Worker #76 (SW) confirmed the event had not been reported to State agencies. She related the director of nursing (DON) had handled it, and that she had not reviewed it. e) Criminal background checks The Affordable Care Act and West Virginia Code Chapter 16, Article 49 required nursing facilities, at a minimum, complete State and Federal fingerprint-based criminal investigation background checks prior to hire. Personnel records, reviewed on 01/13/16 at 1:52 p.m. with Medical Records (MR) #70 revealed no evidence the facility completed a State and Federal criminal background check for Physical Therapist (PT) #108, prior to hire on 10/15/15. A review of the time sheet, on 01//13/16 at 2:55 p.m., confirmed PT #108 had worked on 11/27/15, 12/19/15, 12/24/15, and 01/01/16. An interview with the administrator on 01/13/16 at 3:20 p.m. revealed the contracted company was responsible for completing criminal background checks, and confirmed a fingerprint background check was not completed. f) Policy Review On 01/13/16 at 8:40 a.m., review of the abuse and neglect policy, located in a binder at the nurses ' station, revealed the chain of command was to report to the immediate supervisor, and the facility would take whatever measures were necessary to protect the victim. It indicated the facility would review the work schedule and identify staff who had worked up to 72 hours prior to the event and each employee would be questioned individually. A form indicating the date, time reported, response and description of abuse was to be placed under the door of the social worker or administrator. The facility failed to protect Resident #48 by not identifying his allegations of neglect and not investigating those allegations. The policy further stated, Training .Each employee must understand that it is a requirement by law to report any allegation of abuse, neglect, or misappropriation of a residents property .Each employee is considered a mandated reporter. Prevention: In order to eliminate the possibility of abuse or neglect actually happening, the key item must deal with prevention. Prevention is accomplished by the education of staff, the residents and their families s to what constitutes abuse, neglect, and misappropriation of residents property. In addition to education, we must constantly monitor to assure those policies and procedures are being followed and each of us plays an important role in its implementation. The facility will require all newly hired employees to read and review the patients ' bill of rights and the abuse and neglect policy to ensure that each individual hired is aware of their responsibilities and will follow established policy and procedures . A review of the facility policy revealed the following in regards to screening employees, In order to protect all residents, during the hiring process a newly hired employee will be screened. This will be accomplished through the local law enforcement, state police and other agencies. Once the checks have been completed and show no evidence of abuse or neglect the employee will then be fingerprinted and a background check is then initiated. The employee will be allowed to work until the background check comes back to facility. If the report is unfavorable, the individual will be terminated immediately.",2019-07-01
4789,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2016-01-20,246,D,0,1,V5RK11,"Based on observation, resident interviews, and staff interview, the facility failed to provide reasonable accommodations for one (1) of thirty-five (35) Stage 1 sample residents. Resident #48 was unable to access the pull cord for the over-bed lights. Resident identifier: #48. Facility census: 81. Findings include: a) Resident #48 During Stage 1 room observations for Resident #48, on 01/11/16 at 1:58 p.m., the resident reported he was unable to reach the pull cord for his over-bed light. The pull cord enabled him to turn on his light. Observations at this time revealed the pull cord for the over-bed light was too short for the resident to reach. The observation of the light cord being too short for Resident #48 was discussed with the Director of Maintenance on 01/21/16 at 10:05 a.m. He stated the resident needed to be able to turn his light on.",2019-07-01
4790,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2016-01-20,253,E,0,1,V5RK11,"Based on observations and staff interview, the facility failed to provide maintenance and housekeeping services necessary to maintain a comfortable and sanitary interior for eight (8) of twenty nine (29) rooms observed during Stage 1 of the Quality Indicator Survey (QIS). Rooms 104, 305 and 306 had sink tops with rough edges and a white film around the sinks. Rooms 102 and 203 had furniture with damage. Room 204 needed a longer pull cord for the over- bed light and Rooms 300 and 100 had an unpainted bathroom door and cove base pulled away from the wall. This had the potential to affect more than an isolated number of residents. Room identifiers: #100, #102, #104, #203, #204, #300, #305 and #306. Facility census: 81. Findings include: a) Sink tops --Room #104 was observed, on 01/11/16 at 12:47 p.m., to have white film on the sink top. --Room #305 was observed, on 01/12/16 at 9:55 a.m., to have rough edges on the front of the sink base and a white film around the sink. --Room #306 was observed, on 01/12/16 at 8:30 a.m., to have rough edges on the front of the sink base and a white film around the sink. b) Furniture --Room #102 was observed, on 01/11/16 at 1:09 p.m., to have a night stand with missing veneer. --Room #203 was observed, on 01/11/16 at 12:13 p.m. Room #203 had a four (4) drawer chest with missing veneer and drawers that were not closing properly. c) Light pull cord --Room #204 was observed, on 01/11/16 1:58 p.m., to have a short over-bed light pull cord. d) Door and cove base --Room #300 was observed, on 01/12/16 at 9:01 a.m., to have a bathroom door with unpainted areas. --Room #100 was observed, on 01/11/16 at 12:47 p.m. Room #100 had cove base pulling away from the wall. During an interview with the Maintenance Director on 01/21/16 at 9:45 a.m., agreed the sink tops, furniture, light pull cord, bathroom door and cove base all needed repaired.",2019-07-01
4791,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2016-01-20,278,D,0,1,V5RK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the quarterly minimum data set (MDS) assessment accurately reflected the [DIAGNOSES REDACTED].#3 and #47. Section I - Active [DIAGNOSES REDACTED]. Resident identifiers: #3 and #47. Facility census: 81. Findings include: a) Resident #3 A review of the medical record, for Resident #3 on 01/13/16 at 7:50 a.m., revealed the quarterly MDS assessment with the assessment reference date (ARD) of 10/15/15 did not accurately reflect a [DIAGNOSES REDACTED]. During further review, it was noted in the physician's orders [REDACTED].#3 had an order for [REDACTED]. An interview on 01/13/15 at 8:22 a.m., with Registered Nurse (RN) #86, the RN verified Section I - Active [DIAGNOSES REDACTED].#3. b) Resident #47 The MDS assessment review for Resident #47 on 01/19/16 at 11:00 a.m. revealed an MDS with the assessment reference date of 12/26/15. The 14 day PPS MDS Minimum Data Set Assessmt (MDS) with the assessment reference date (ARD) of 12/26/15 indicated the assessment did not include the [DIAGNOSES REDACTED]. Review of the MDS significant change with ARD of 12/15/15 did indicate the resident had a [DIAGNOSES REDACTED]. This [DIAGNOSES REDACTED]. Discussion with the MDS Coordinator on 01/19 /16 at 10:15 a.m. revealed the [DIAGNOSES REDACTED]. Current physician's orders [REDACTED].",2019-07-01
4792,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2016-01-20,279,E,0,1,V5RK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff interview it was determined the facility had not included goals for advanced directive specifics or end of life care on resident care plans. This would ensure staff members would provide treatment in accordance with resident wishes. This included seven (7) of seven (7) residents in the Stage 2 sample which were reviewed for advanced directives. Resident identifiers: #17, #95, #42, #100, #3, #98, and #29. Facility census: 81. Findings include: a) Resident #17 Review of the medical record, 01/19/16 at 10:00 a.m., for this resident revealed there were orders for comfort measures only. The current care plan did not address the resident's advanced directives. The Physician order [REDACTED]. The resident's advance directives and specific wishes for end of life were not identified in the care plan. An interview with Registered Nurse (RN) #86 on 01/20/16 at 9:30 a.m revealed that they had not been placing he advanced directive issues as part of the care plan. b) Resident #95 A review of the medical record, on 01/20/16 at 10:30 a.m., revealed the resident had orders for Do Not Resuscitation. The care plan did not include any specifics regarding the advanced directives. The POST form dated 08/24/15 had Do Not Resuscitation indicated. Other directives were IV fluids long term if needed and feeding tube long term. These were not in the current care plan to ensure the staff would implement the resident's wishes. Discussion with nursing staff as listed above. in example a. c) Resident #42 Review of Resident #42's medical record, on 01/20/16 at 10:30 a.m., showed the resident had a POST form, which indicated the following directives should be implemented per his wishes: The POST form revealed that he wanted full measures taken, IV for long term and no tube feeding. However, the care plan stated comfort measures were to be implemented. These directives were not in the current care plan. RN #86 was interviewed on 01/20/16 at 9:30 a.m. and it was found he really felt he wanted everything done, he could fight this illness but he was hospitalized and did expire there shortly after admission. d) Resident #100 A review of Resident #100's West Virginia Physician order [REDACTED]. The resident wanted comfort measures, no intravenous fluids, and no feeding tube. A review of Resident #100's care plan, on 01/14/16 at 9:05 a.m., revealed there were no care plan related to her advance directive. In an interview on 01/14/16 at 9:20 a.m., with the minimum data set coordinator (MDSC) #78, she was asked whether Resident #100 had a care plan related to her advance directives. MDSC #78 reviewed Resident #100 ' s care plan and she stated, We did not do a care plan related to her advance directive. During an interview, on 01/14/16 at 10:00 a.m., Social Worker #76 stated, She had not initiated an advance directive care plan for Resident #100. She confirmed that she knew that all residents should have an advance directive care plan. e) Resident #3 A review of the medical record, on 01/13/16 at 7:30 a.m., revealed the comprehensive care plan did not include any advance directives regarding end-of-life wishes or care interventions for Resident #3. During further review, it was noted the physician's orders [REDACTED]. An interview on 01/13/15 at 8:42 a.m., with RN #86, verified this resident's comprehensive care plan did not include her advance directives or end-of-life wishes. f) Resident #98 A review of the medical record, on 01/20/16 at 4:23 p.m., revealed the comprehensive care plan did not include any advance directives regarding end-of-life wishes or care interventions for Resident #98. During further review, it was noted the physician's orders [REDACTED].>An interview, on 01/20/16 at 4:35 p.m., with RN #86, verified this resident's wished to be resuscitated and this was not addressed on her comprehensive care plan. g) Resident #29 A review of the medical record, on 01/13/16 at 7:50 a.m., revealed the comprehensive care plan did not include any end-of-life wishes or care interventions for this resident. During further review, it was noted the physician's orders [REDACTED]. An interview, on 01/13/15 at 8:42 a.m., with RN #86, verified this resident's comprehensive care plan did not include advance directives regarding her end-of-life wishes.",2019-07-01
4793,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2016-01-20,309,D,0,1,V5RK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and medical record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental or psychosocial well-being for one (1) of five (5) residents reviewed for unnecessary medications. The facility failed to adequately assess and monitor a resident who experienced an exacerbation of [MEDICAL CONDITIONS]. Resident identifier: 96. Facility census: 81. Findings include: a) Resident #96 During a Stage 1 interview, on 01/11/16 at 1:10 p.m., Resident #96 expressed he utilized an inhaler for shortness of breath. The resident related, I had to give my inhaler up. When you need it, you just smother. Here you have to ask for it .I don't (do not) like it at all. Sometimes I go up there and there is no one at the desk at all, and I smother and am uncomfortable, and it makes me mad. I am not mental. Upon inquiry, the resident related he had not discussed it with the physician, but I talk to the nurse all the time. They can't (cannot) do anything unless he tells them. Don't (Does not) make sense to me. Sometimes I go out there and there is two (2) of them, and they are busy doing other things and had to wait. The resident related he always had one on me, wherever I went, I had it, but they took it away from me here. The resident related he had been in the facility about two (2) months. Another interview with Resident #96, on 01/13/16 at 8:31 a.m., revealed his status as I'm (I am) fair. I'd (I would) say I am fair. The resident further added, I just can't (cannot) seem to connect here. The resident related he would go to the hospital, and sometimes had to wait a long time, but would sit and converse with other men. The resident said he was able to talk about his feelings and they would give him nerve pills. The resident related he was unsure of what the facility administered him, but indicated he used inhalers and took a blood thinner medication to keep him from having a [MEDICAL CONDITION]. It beats real fast. Review of the minimum data set (MDS) with the admission minimum data set (MDS) with an assessment reference date (ARD) of 11/16/15, on 01/12/16 at 2:31 p.m. revealed in section I, a [DIAGNOSES REDACTED]. A brief interview for mental status (BIMS) score in section C indicated the resident was moderately cognitively impaired. A pharmacy recommendation, dated 12/08/15 indicated the resident requested the addition of [MEDICATION NAME] and [MEDICATION NAME] for memory. An activity assessment, dated 11/11/15 indicated Resident #96 was oriented to person, place, time, family, season and year. Review of the care plan, on 01/19/16 at 3:41 p.m., revealed an alteration in cognition and communication and interventions included attempting to include the resident in his own self-care duties to improve self-care ability, autonomy of care, breathing treatments, and inhalers due to shortness of breath and promote opportunities to participate in decisions regarding care. The care plan revealed the resident had an exacerbation of [MEDICAL CONDITIONS], and indicated Resident #96 was treated with antibiotic therapy, a [MEDICATION NAME] dose pack (steroid therapy), and inhalation treatments via nebulizer. It noted staff should notify the physician of a decreased SAO2 (direct measurement of the saturation of hemoglobin with oxygen in arterial blood.) Further review of the medical record, on 01/19/16 at 5:28 p.m. revealed no evidence of SAO2 (percentage of oxygen saturation of arterial blood) results in the weight/vital signs section of the electronic medical record (EMR). Medication sheets, reviewed for the months of November, (MONTH) and (MONTH) revealed no evidence the resident had received a dose of [MEDICATION NAME] HFA (prescription inhaled medicine used to treat [MEDICATION NAME]), although an interview with Licensed Practical Nurse #101 on 01/20/16 at 2:30 p.m. related the resident asked for, and received the medication, usually in the evenings. physician's orders [REDACTED]. Other medications related to [MEDICAL CONDITION] included [MEDICATION NAME] inhaler 18 micrograms (mcg) one time a day, [MEDICATION NAME] HFA Aerosol Solution 108 (90) base mcg/act ([MEDICATION NAME] sulfate HFA) two (2) puffs inhale orally every six (6) hours as needed for [MEDICAL CONDITION]; [MEDICATION NAME] aerosol (medication used to prevent broncospasm in people with asthma or [MEDICAL CONDITIONS] 160-4.5 mcg ([MEDICATION NAME]-[MEDICATION NAME]) two (2) puffs inhale orally twice a day. The facility policy and procedure manual located at the nurse's station was reviewed on 01/13/16 at 9:20 a.m. The policy contained nursing tips for F329 which indicated the nurse should monitor, assess, and document the effectiveness of a medication regime. Progress notes, reviewed on 01/20/16 at 2:30 p.m., with Registered Nurse #18 and LPN #101, revealed no evidence the facility had adequately monitored the residents lung sounds and/or vital signs. The notes indicated on: --01/08/16 orders were received for a chest x-ray was ordered due to congestion and a productive cough, a sputum culture, and a flu swab for malaise (feeling of general discomfort) and fatigue. The sputum expectorated noted to be green mucus like texture. Complaints of malaise at this time, vital signs obtained with a temperature of 97.9 axillary, Pulse 102 ) No assessments were noted for 01/09/16, 01/10/15, 01/11/16, 01/12/16, 01/13/16, or 01/14/16. --01/15/16 a physician's orders [REDACTED]. New orders were received for [MEDICATION NAME] 875-125 milligrams (mg), a [MEDICATION NAME] dose pack, [MEDICATION NAME] (nebulizer breathing treatments), and every eight (8) hours for seven (7) days for exacerbation of [MEDICAL CONDITION] ([MEDICAL CONDITION].) No evidence of a [MEDICAL CONDITION] (lung) assessment was noted on 01/16/16, 01/17/16, 01/8/16, or 01/19/16. --An entry dated 01/20/16 indicated Lung sounds noted to be wheezing . The assistant director of nursing (ADON) #34 on 01/20/2016 at 4:22 p.m. related nurses should have completed assessments which included lung sounds, SPO2 (indirect measurement of the saturation of hemoglobin with oxygen in arterial blood. Measurement is taken using a finger probe or ear sensor) (not required but nursing measure), and noted a cough productive/non-productive, congestion when there was a change in condition or as long as the resident received antibiotic therapy. The ADON confirmed the facility had not adequately assessed the resident's respiratory status.",2019-07-01
5809,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2014-10-22,253,D,0,1,CW7M11,"Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services to ensure a sanitary, orderly and comfortable interior. Furniture in resident rooms was in need of repair. Bathrooms had scraped doors, missing tiles around the commode, and a sink front needed repair and new caulking. This had the potential to affect more than an isolated number of residents. Facility Census: 78 Findings include: a) Furniture -- Room #100 On 10/15/14 at 9:40 a.m. an observation of Room 100 revealed the wardrobe drawer was missing a knob. -- Room #305 At 10:18 a.m., on 10/15/14, an observation of Room 305 revealed the wardrobe doors were sprung and would not close properly. The bathroom doors and door facings needed painted and there were cracked floor tiles. -- Room #109 At 2:39 p.m., on 10/14/14, an observation of Room 109 revealed the bathroom door had the finish scraped off down to the bare wood. -- Room #309 On 10/15/14, at 10:27 a.m., an observation of Room 309 revealed the bathroom door had the finish scraped off down to the bare wood. -- Room #311 At 9:57 a.m., an observation of Room 311 revealed the bathroom door had the finish scraped off down to the bare wood. -- Room #315 At 4:20 p.m., on 10/14/14, an observation of Room 315 revealed the bathroom door had been damaged and the wood veneer was splintered. -- Room #111 An observation of Room 111 on 10/15/14 at 10:00 a.m. revealed the bathroom door facings had the paint scraped off and the wood was exposed. -- Room #109 On 10/14/14, at 2:39 p.m., an observation of Room 109 revealed the tile around the commode was cracked and separated. c) Vanity sinks -- Room #109 At 2:39 p.m. on 10/14/14 an observation of the vanity sink in Room 109 revealed the front of the sink had a large piece of Formica missing, exposing an unfinished surface. -- Room #105 At 4:14 p.m., on 10/14/14, observation revealed Room 105 had stained caulking around the vanity sinks. The caulking needed replaced. -- Room #315 An observation of the vanity sink in Room 315 on 10/14/14 at 4:20 p.m. revealed the caulking around the vanity sink was stained and in need of replacement d) On 10/21/14, at 3:55 p.m., during an observation of the eight (8) rooms with the Maintenance and Housekeeping Supervisor, the supervisor verified the wardrobes, bathroom doors, door facings, cracked tile and the vanity sinks were all in need of repair.",2018-07-01
5810,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2014-10-22,314,D,0,1,CW7M11,"Based on observation, staff interview, Lipincott Nursing Procedure review, and policy review, the facility failed to ensure a resident received the necessary care and services to promote healing and prevent infection. Staff utilized improper technique when cleansing pressure ulcer wounds creating a potential for introducing microorganisms into the resident's wounds. This was found for one (1) of one (1) resident observed with pressure ulcers. Resident identifier: #59. Facility census: 78. Findings include: a) Resident #59 During an observation of wound care, on 10/21/14 at 6:30 a.m., Employee #84, a licensed practical nurse (LPN), completed wound dressing treatments to five (5) pressure ulcer wounds for Resident #59. The nurse first changed the dressing to the left heel. The nurse poured saline over gauze and then dabbed the whole wound bed with the same gauze. She rolled the resident to his left side. Observation revealed the dressing to the right buttock was not intact, and the resident had defecated (bowel movement). When cleaning the wound bed, the LPN cleansed the wound from the center to the outer aspect of the wound bed, wiped the peri wound area, then dabbed the wound bed again with the same gauze. The nurse washed her hands, before applying the clean dressing. Upon inquiry, she related the technique for cleaning wounds included cleaning from the inner to the outer part of the wound. With further inquiry, she related the way she cleansed the wounds posed a potential for cross contamination. She related organisms from the skin could be transmitted to the wound causing infection and delayed healing. Review of the wound care policy, on 10/21/14 at 1:30 p.m., indicated staff cleanse the wound with solution, cleaning area inside out. An interview with the director of nursing, on 10/21/14 at 4:30 p.m., revealed Employee #84 had spoken with her and related she had utilized improper technique. The director of nursing concurred the improper technique created a potential for contamination of the wound bed and did not follow the standard of practice. According to Lippincott Nursing Procedures (WOUND WISE: Basic wound cleaning step by step Nursing Made Incredibly Easy! September/October 2008 Volume 6 Number 5, Pages 30-31, found at www.nursing center.com/Inc/static?pageid= 4), to prevent contamination and potential infection when cleaning an open wound, such as a pressure ulcer, the area should be gently wiped in a circular motion starting directly over the wound and moving outward.",2018-07-01
5811,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2014-10-22,371,E,0,1,CW7M11,"Based on observation and staff interview, the facility failed to store foods in the nutrition pantry in a manner to prevent the potential for foodborne illnesses. Uncovered food was stored in the refrigerator in the nutrition pantry. This practice had the potential to affect more than an isolated number of residents. Facility census: 78. Findings include: a) During the initial tour of the facility on 10/07/14 at 1:50 p.m., the nutrition pantry located in the hallway between the east and west wings of the facility was observed. Employee #85, a nursing assistant (NA), unlocked the door of the nutrition pantry. Observation of the contents of the refrigerator, with the NA, revealed an uncovered container of a moist pink substance on the second shelf. The nursing assistant did not know the contents of the uncovered container. At 1:54 p.m., the Director of Nursing (DON) came into the nutrition pantry. The DON agreed the facility had not stored the food in the proper manner. The DON identified the food item as ham salad and said she would find out who made the last ham salad sandwich. The DON discarded the ham salad at that time.",2018-07-01
7514,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2013-07-19,253,E,0,1,NOYK11,"Based on observation and staff interview, the facility failed to provide maintenance services to maintain resident rooms and furnishings in good repair. in seven (7) rooms on the 300 hall. Rooms #302, #304, #305, #307, #312, #313, and #315 all contained wardrobes for resident clothing which were missing knobs. The knobs were necessary to assist residents in opening and closing the drawers. Room #307 also had a hole in the wall where the cable outlet was connected. The outlet cover was hanging on the cable that ran from the wall to the television. This practice had the potential to affect more than an isolated number of residents. Facility Census: 80. Findings Include: a) Room #307 Random observations completed during Stage 1 of the survey, at 4:54 p.m. on 07/15/13, revealed the wardrobes in Room #307 had drawers with missing knobs. Without the knobs it was difficult to open and close the drawers. Also observed was a square hole in the drywall with a black cable. The cable ran from the hole to the television sitting by the window. The black cable had a cream-colored outlet cover hanging on it with the cable running through a small hole in the center of the outlet cover. The outlet cover appeared to have at one time been screwed into the wall covering the hole. Employee #28, a maintenance employee, was interviewed at 1:45 p.m. on 07/17/13. He made an observation of Room #307 and confirmed the cable outlet cover was pulled from the wall exposing the hole, which was made to run a cable to the room for television access. Employee #28 also confirmed the drawers were missing knobs. He stated they would compile a list to get them replaced. b) Rooms #302, #304, #305, #312, #313, and #315. Random observations were made during Stage 2 of the survey, at approximately 1:00 p.m., on 07/17/13. The observations revealed all of these rooms had missing knobs on the drawers of the wardrobes which contained residents' clothes. This made it difficult to open and close the drawers. Employee #28 confirmed there was a problem on this hallway with missing drawer knobs and reported they would work to get them replaced. He stated they were in the process of remodeling the rooms and the wardrobes would not contain drawers. He stated they had not gotten to the 300 hall in the remodeling process.",2017-04-01
7515,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2013-07-19,272,D,0,1,NOYK11,"Based on medical record review and staff interview, it was determined the Minimum Data Set (MDS) assessment for one (1) of twenty-one (21) residents whose medical records were reviewed, contained an assessment which had inaccurate data regarding use of a urinary catheter. Resident #96 had a catheter identified on the current assessment, but this device had been removed months prior to the current assessment being completed. Resident identifier: #96. Facility census: 80. Findings include: a) Resident #96 Review of the quarterly MDS assessment, completed on 06/03/13, indicated the resident had an indwelling Foley catheter. An interview with the director of nursing, Employee #58, at 10:20 a.m. on 07/17/13, revealed the resident did not currently have a catheter and it had been removed back in March 2013. She could not determine why the MDS indicated the resident had a catheter when it had not been used for some time.",2017-04-01
7516,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2013-07-19,323,E,0,1,NOYK11,"Based on observation and staff interview, the facility failed to maintain an environment free from accident hazards. During a random observation of the facility's shower room, an electric hairdryer was observed hanging unattended and plugged into an electrical outlet near a water source. This had the potential to affect more than a minimal number of residents. Facility Census: 80. Findings Include: a) During a random observation, at 2:15 p.m. on 07/18/13, an electric hairdryer was observed hanging on a towel hook in the facility shower room. The hairdryer was plugged into the electrical outlet and was located near the sink in the shower room. At 2:20 p.m. on 07/18/13, Employee #79, a Licensed Practical Nurse (LPN), accompanied the surveyor to the shower room. When Employee #79 saw the hairdryer she stated, They know better than this. She unplugged the hairdryer and stated the hairdryer was to be kept in the locked cabinet on the wall across from the sink. She stated when the hairdryer was not in use, the staff should put the hairdryer in the cabinet, and should not leave the hairdryer plugged in unattended.",2017-04-01
7517,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2013-07-19,431,E,0,1,NOYK11,"Based on observation, policy review, and staff interview, the facility failed to ensure the safe and secure storage of controlled medications. The refrigerated controlled substances were not stored in a permanently affixed locked compartment. This practice had the potential to affect a limited number of residents. Facility census: 80. Findings include: a) During the visual check of the West wing medication storage room, on 07/17/13 at 2:45 p.m., the medication storage refrigerator was noted to have a clear locked box containing four (4) vials of Lorazepam 2 mg/ml injectable. The box was not secured inside of the refrigerator and the refrigerator was not locked to secure the controlled substances. The facility did not maintain a separately locked, permanently affixed compartment for the storage of controlled medications. During an interview with the director of nursing (DON), on 07/17/13 at 2:50 p.m., she was made aware the vials of Lorazepam were not in a secure box. She asked how this could be done. She stated she felt the medications being in the box that was locked and the medication room door was locked, the medications were secured. She stated she was going to notify the pharmacy to get the box secured inside of the refrigerator. Review of the facility's policy, on 07/18/13 at 10:00 a.m., entitled 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles number twelve (12) Controlled Substances Storage included, Number 12.1 Facility should ensure that Schedule II-IV controlled substances are only accessible to licensed nursing, Pharmacy, and medical personnel designated by the Facility. Number 12.2 was After receiving controlled substances and adding to inventory, Facility should ensure that Schedule II-IV controlled substances are immediately placed in a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable Law).",2017-04-01
7518,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2013-07-19,514,D,0,1,NOYK11,"Based on medical record review, facility policy review, and staff interview, the facility failed to ensure the completeness and accuracy of two (2) of twenty-one (21) medical records. Resident #27's medical record did not contain complete documentation pertaining to social services provided by the social worker. Resident #66's medical record did not contain complete documentation for pressure ulcers. Resident identifiers: #27 and #66. Facility census: 80. Findings include: a) Resident #27 On 07/18/13 at 2:00 p.m., the social worker (Employee #50) said she had files for residents she had talked with in her office in a file cabinet. She said these records were secure in her office in the locked cabinet. She said they contained sensitive information and she did not believe she should put that type of information in the resident's electronic medical record. She said she had a file for Resident #27. She explained some of the conversations she had with Resident #27 and did not feel she should put these conversations and their content in the electronic medical record for all staff to view. According to AHIMA (American Health Information Management Association) long-term care guidelines (06/09) a complete medical record contains an accurate and functional representation of the actual experience of the individual in the facility. It must contain enough information to show that the facility knows the status of the individual has adequate plans of care and provides sufficient documentation of the effects of the care provided. Documentation should provide a picture of the resident, including what resident said or did, observations and/or assessments by staff, communications with practitioners and legal representative, response to interventions/treatment. Good practice indicates that for functional and behavioral objectives the clinical record should document change toward achieving care plan goals. The social worker verified Resident #27 had episodes of verbal aggression toward staff and other residents. She said the facility had care planned this issue. She said part of her interventions with him involved talking with him when he became upset to determine what had caused him to get angry. She also would talk with him about ways to redirect this anger and encourage him not to become verbally aggressive with others. She indicated some of her conversations with this resident were documented in the files she kept in her office. On 07/19/13 at 9:30 a.m., the office manager (Employee #10) provided a copy of the facility's policy on health information management. The health information policy stated The facility administrator has overall responsibility for assuring that clinical records are maintained, complete, preserved, and kept confidential in accordance with applicable standards, practices, laws, and regulations. b) Resident #66 A medical record review was completed at 11:30 a.m. on 07/18/13. This review revealed a body audit with Resident #66's name written at the top of the form. The body audit identified skin alterations including measurements at different places on the resident's body. Employee #44, a Licensed Practical Nurse (LPN), was interviewed at 11:30 a.m. on 07/18/13. She stated the body audit was likely done on admission, but confirmed it was not signed or dated. She confirmed there was no way to determine when the body audit was completed or by whom the body audit was completed. Review of the facility's Clinical Record Guidelines, at 9:03 a.m. on 07/19/13, revealed the following paragraph, A separate clinical record shall be maintained for each resident admitted to the Facility and the resident's name will be placed on all clinical record forms. All physicians, nursing staff, and other health care professionals involved in the resident's care will be responsible for making prompt, appropriate entries in the clinical record and authenticating them with date, signature and title. This was confirmed with Employee #10, the office manager, as the guidelines the facility followed to maintain the residents' medical records.",2017-04-01
7707,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2014-02-19,253,D,1,0,70SM11,"Based on random observation and staff interview the facility failed to provide housekeeping services necessary to maintain a sanitary and comfortable interior. The facility failed to clean a table before serving a resident food on that table. Resident Identifier: #40. Facility census: 83. Findings Include: a) Resident #40 During initial tour of the facility on 02/17/14 at 1:00 p.m., a dining table in the east dining room had a soiled area approximately the size of a dinner plate. The area had a dried dark brown appearance. On 02/17/14 at 5:15 p.m., the same soiled area remained on the east dining room table. At 5:30 p.m., Resident #40 went into the dining room to wait for her dinner tray. Resident #40 motioned for this surveyor to come to the dining room. She pointed at the soiled table and made hand motions to suggest she wanted the table cleaned. At 6:00 p.m., on 02/17/14, Resident #40 ' s dinner was served in the east dining room. Employee #14 (nurse aide) placed the tray on the table on top of the soiled area. At the same time, Employee #14 stated she did not notice the soiled area and would clean the area. On 02/19/14 at 1:30 p.m., nursing assistant supervisor, Employee #19 agreed the facility should have cleaned the table prior to serving a resident dinner, on the table.",2017-02-01
7708,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2014-02-19,280,D,1,0,70SM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observation, and incidents/accidents report review, the facility failed to revise and implement a care plan for one (1) of nine (9) residents. The facility did not utilize the care plan when Resident #14 had an exacerbation of aggressive behaviors. Additionally, the facility did not revise the care plan to include effective interventions for staff to utilize regarding the resident's pain during ambulation. Resident identifier: #14. Facility census: 83 Findings include: a) Resident #14 1) The incident/accident reports reviewed, on 02/17/14 at 2:00 p.m., revealed Resident #14 had a history of [REDACTED]. A review of behaviors revealed the resident had hallucinations, delusions, and exhibited both verbal and physical behaviors during the assessment period. Resident #14's [DIAGNOSES REDACTED]. The care plan, dated 01/29/14, and reviewed on 02/17/14 at 3:50 p.m., noted a focus related to psychosocial well-being related to distractibility/inability to concentrate. It also described impaired cognitive function/dementia or impaired thought processes related to impaired decision making (has short attention span). The interventions for this focus area included: engage in simple, structured activities that avoid overly demanding task, verbal praise, play a variety of music when she is upset to try to calm her, invite and assist resident to social activities such as parties, church, sing-a-longs and socials. The medical record review provided no evidence the facility implemented these interventions during acts of aggression from 01/22/14 through 01/27/14. Random observations were made during the survey. Throughout the day on 02/17/14, from 11:45 a.m. to 7:15 p.m. the resident was observed sitting in a small dining area across from the nurse's station or in her room. This was also observed on 02/18/14 from 9:00 a.m. to 7:15 p.m. and on 02/19/14 from 9:00 a.m. to 4:00 p.m. There was no evidence present indicating staff engaged the resident in structured recreational activities. There was also no music was playing while she was in her room. A review of the incident/accident reports and medical record review revealed the following interventions related to resident-to-resident altercations: - 01/22/14 at 16:13 (4:13 p.m.): Staff reported the resident went into another residents room, poured out the other residents water on to floor, and was slapping other resident, who was lying in her bed, in the chest. Resident was removed from common area teaching was attempted with resident to not hit other residents that this behavior is inappropriate. Resident stated, I can do what I want and cursed staff. Immediate action: Removed from the other resident's room and explained to her that this was inappropriate behavior but she voiced no understanding. - 01/24/14 at 19:25 (7:25 p.m.) (typed as written): This nurse heard someone yelling for help. As nurse walked into the lounge and noticed Resident #14 grabbing another resident by the shirt and hands. Res began to squeeze the other Res hand and was mumbling. This nurse separated the two Residents and explained to Res that this type of behavior would not be tolerated. Res showed no understanding. MD aware. Attempted to notify POA without success. Staff will continue to monitor behavior. Res showed no understanding . Immediate action: This nurse separated the two Residents and explained to Res that this type of behavior would not be tolerated. - 01/25/14 at 16:00 (4:00 p.m.): Staff reported this resident went into dining room and started hitting another resident on the left shoulder. Staff removed Resident #14 from dining room and brought her back to west side nurses station. Staff sat and talked with resident. Other resident was assessed for injuries. Spoke with Dr. (name) regarding residents behavior with new order for [MEDICATION NAME] 1 mg (milligram) PO (by mouth) x 1 dose now. - 01/27/14 at 5:53 p.m., Staff reports that this resident entered another resident room and began smacking her in the face 2-3 times. - 01/28/14 at 6:29 a.m. (typed as written): Called into front of dietary by staff to see res (resident) holding on to another res (resident) w/c (wheelchair). Staff stated that this res (resident) had scratched another res (resident) on the face. Res (resident) was immediately removed from the other res (resident) area and taken to another hall. Res (resident) unable to understand her behavior and teaching was ineffective. Will cont (continue) to mont (monitor) res (resident) behavior. - 01/28/14 at 11:18 a.m., staff Heard another resident yelling and went to where residents were sitting and this res (resident) was twisting the right hand of another resident. Removed from situation. Res combative with this nurse. Immediate action: . Attempted to talk with resident with no positive outcome. Both residents are confused. An entry on 02/03/14 indicated, MD has made a med review and has made medical changes to [MEDICAL CONDITION] medications. An interview with the physician and Employee #92, a registered nurse (RN), on 02/18/14 at 4:15 p.m., revealed the care plan was not revised to provide effective non-pharmacological interventions. Both the physician and the RN confirmed staff had not identified a pattern of occurrences, such as the time/shift of occurrence, which would affect the care plan. On 02/18/14 at 5:00 p.m., during an interview with the administrator and quality coordinator RN, they confirmed the facility had not identified interventions utilized by staff were not always understood by the resident; therefore they were not appropriate interventions for this resident. They also confirmed staff had not used the specific interventions identified on the care plan. 2) Restorative progress notes dated 01/24/14 and 01/26/14 indicated the Resident favors left leg during ambulation. Weekly restorative notes, dated 01/31/14 and 02/07/14 noted the resident favored her left leg during ambulation. The restorative notes said the resident denied pain. On 02/13/14, restorative notes indicated the resident continued to favor her left leg and did not participate daily. On 02/11/14, staff observed the resident crying, but was unable to identify the cause. A note dated 02/12/14 related Resident #14 was crying, staff asked her if she had pain, and she attempted to bite the nurse, then hit the nurse. The nurse gave the resident pain medication at that time. A follow-up note indicated the resident was not crying anymore. Review of the resident's care plan revealed a care plan for pain; but nothing related to pain during restorative care and/or ambulation. During an interview with Employee #7 (LPN), on 02/19/14 at 12:37 p.m., the nurse said, I really believe she is having pain, and I was going to talk to staff about medicating her. The nurse said Resident #14 was unable to participate with restorative due to experiencing pain with ambulation. The nurse also acknowledged the facility had not revised the care plan to coordinate efforts with restorative staff for pain relief prior to ambulation.",2017-02-01
7709,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2014-02-19,514,D,1,0,70SM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate clinical records to reflect resident status for two (2) of nine (9) residents whose medical records were reviewed. The care plan for Resident #28 did not correlate with physicians orders. The behavior monitoring sheets for Resident #14 did not accurately reflect the resident's behaviors. Resident identifiers: #14 and #28. Facility census: 83. Findings include: a) Resident #28 Review of Resident #28's medical record revealed a physician order [REDACTED]. An additional physician order [REDACTED]. The resident's care plan, with a revision date of 02/12/14, revealed interventions which stated: Resident to go for [MEDICAL TREATMENT] on Tuesdays, Thursdays, and Saturdays . and Remove dressing from right arm [MEDICAL TREATMENT] fistula on Wednesdays, Fridays, and Sundays . The care plan interventions did not reflect the physician orders. On 02/18/14 at 2:00 p.m., Employee #81, a registered nurse, agreed the records revealed a discrepancy between the physician orders [REDACTED]. b) Resident #14 Incidents/accident reports were reviewed on 02/17/14 at 2:00 p.m. According to the reports, Resident #14 engaged in five (5) acts of aggression in January 2014. The resident engaged in acts of aggression on 01/22/14 at 4:13 p.m., 01/24/14 at 7:25 p.m., 01/25/14 at 4:00 p.m., 01/27/14 at 5:53 p.m. and on 01/28/14 at 11:18 a.m. On 02/18/14 at 3:00 p.m., a review of the behavior monitoring sheets revealed no behaviors were noted for four (4) of the five (5) incidents: 01/22/14, 01/24/14, 01/25/14, and 01/27/14. Registered nurse #92 reviewed the forms at 4:15 p.m., and confirmed they did not portray an accurate clinical record. The director of nursing also reviewed the behavior monitoring reports on 02/18/14 at 5:30 p.m., and confirmed the behavior monitoring sheets did not accurately reflect the resident's status.",2017-02-01
7710,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2014-02-19,520,D,1,0,70SM11,"Based on medical record review and staff interview, the facility's Quality Assessment and Assurance (QAA) committee failed to identify quality deficiencies of which they had, or should have had knowledge. A resident had an exacerbation of resident-to-resident altercations which were not addressed by the QAA committee. The committee failed to develop and implement a plan of action to correct the problem. Resident identifier: Resident #14. Facility census: 83. Findings include: a) Resident #14 The incidents/accident reports were reviewed on 02/17/14 at 2:00 p.m., related to a complaint of resident-to-resident altercations. According to the reports, Resident #14 engaged in multiple acts of aggression in January as follows: -- On 01/22/14 at 4:13 p.m., Resident #14 entered another resident's room and slapped a resident on the chest, while the resident was lying in bed. -- At 7:25 p.m., on 01/24/14 after hearing a call for help, a nurse observed Resident #14 grabbing another resident by the shirt and hands. Resident #14 squeezed the resident's hand causing a reddened area. -- Resident #14 entered the dining room on 01/25/14 at 4:00 p.m., and started hitting another resident on the left shoulder. -- On 01/27/14 at 5:53 p.m., Resident #14 entered another resident's room and began smacking her in the face. The incident report noted she smacked the resident 2-3 times. -- At 6:29 a.m., on 01/28/14, staff observed Resident #14 holding onto another resident's wheel chair. Staff observed Resident #14 scratching the resident on the face. -- Again, on 01/28/14, at 11:18 a.m., after hearing a resident yell, staff observed Resident #14 twisting the right hand of a resident. During an interview with the assistant administrator, on 02/18/14 at 5:00 p.m., he said the facility had not identified a pattern related to the resident-to-resident altercations. He said the QAA committee met in February 2014, but did not address the exacerbation of behaviors exhibited by Resident #14. He acknowledged the facility had not identified that the first four (4) incidents occurred on the evening shift, between 4:00 p.m. and 7:30 p.m. He also acknowledged the facility did not identify inadequate or inappropriate interventions used by staff during the exacerbation of aggression from 01/22/14 through 01/27/14, and had not explored potential causative factors.",2017-02-01
8660,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,156,C,0,1,46GB11,"Based on interview and review of documentation, the facility was not using the correct Centers for Medicare and Medicaid Services (CMS) form when notifying residents of changes in the services being provided them under the plan. Residents are to be notified when they no longer are going to receive Medicare skilled services using form CMS . The facility was using a a form entitled C-4. This was evident for three (3) of three (3) residents whose records for denial of payment for services were reviewed. This practice had the potential to affect any resident who was discharged from Medicare services. Resident identifiers: #40, #26 and #70. Facility census: 76. Findings include: a) Residents #40, #26, and #70 Review of documentation given these residents, when they no longer qualified for Medicare services, revealed the facility was using a form entitled C-4. This was not the required form as specified by CMS. The form specified by CMS is form CMS . This is the form to be given at the time residents are no longer eligible for skilled services. Such reasons include: when a resident has used all their days, has reached his/her potential, and/or for any reasons, as set forth by CMS, in which Medicare services are discontinued. This was discussed, on 01/09/12 at mid-morning, with the business office manager(Employee #63) who was responsible for providing these notices. Employee #63 stated he was not aware of form CMS , and would begin using it immediately.",2016-04-01
8661,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,157,D,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the responsible party and physician of a resident's continued refusal to allow staff to obtain laboratory specimens. This practice affected one (1) of forty-two (42) sampled residents. Resident identifier: #10. Facility census: 76. Findings include: a) Resident #10 Review of this resident's physician's orders [REDACTED].#10 was ordered a basic metabolic profile (BMP) every four (4) months and a complete blood count (CBC) every six (6) months. Review of the medical record found no laboratory services. Further review of the medical record found the following nursing documentation entries: -- 06/08/11 at 536 -- Resident cont (continues) to refuse to let staff obtain routine schedule labs after several attempts made. Will continue to keep trying to obtain. -- 06/22/11 at 14:20 -- Resident refuses to let staff obtain labs after several attempts made. Will continue to keep trying to obtain. -- 07/22/11 at 12:39 -- Resident refuses to let staff obtain routine labs after several attempts made per staff. Will continue to keep trying to obtain. -- 07/27/11 at 13:27 -- Resident cont to refuse to let staff obtain routine schedule labs after several attempts made per staff. Resident states 'you are not getting any of my blood'. -- 07/29/11 at 09:34 -- Resident cont to refuse to let staff obtain labs after several attempts made. Will continue to keep trying to obtain. -- 08/04/11 at 13:12 -- Resident continues to refuse to let staff obtain labs after several attempts made per staff. will continue to keep trying to obtain. -- 08/12/11 at 12:13 -- Resident continues to refuse to let staff obtain routine labs after several attempt made per staff. Will cont to keep trying to obtain. -- 08/22/11 at 13:56 -- Resident continues to refuse to let staff obtain routine schedule labs after several attempts made per staff. Will continue to keep trying to obtain. -- 09/08/11 at 11:37 -- Resident continues to refuse to let staff obtain routine schedule labs after several attempts made per staff. Will continue to keep trying to obtain. Review of the medical record found no attempts made by the facility to contact Resident #10's responsible party or the physician regarding the resident's refusals to allow blood drawn for ordered lab work. An interview conducted, during the afternoon of 01/09/12, with Employee #74, the minimum data set nurse, confirmed the facility did not notify the responsible party or the physician after Resident #10 refused laboratory services on the dates listed above.",2016-04-01
8662,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,160,B,0,1,46GB11,"Based on review of residents' personal funds and staff interview, the facility failed to convey residents' funds, and to provide a final accounting of those funds, to the individual or probate jurisdiction administering the residents' estates. Instead, the facility paid the residents' funds to the funeral home and did not provide a final accounting of the residents' funds to a legally authorized individual or probate jurisdiction administering the estate. This practice affected three (3) of three (3) sampled residents. Resident identifiers: #2, #9, and #100. Facility census: 76. Findings include: a) Residents #2, #9, and #100 Review of the facility's personal funds accounting records found these three (3) residents' final accounts were paid directly to a funeral home. During an interview, on the afternoon of 01/11/12, a business office manager, Employee #63, confirmed when a resident passed away the facility did provide a final accounting of the residents' funds, and did not send the funds to the individual or probate jurisdiction administering the resident's estate. Employee #63 stated, All funds go directly to the funeral home.",2016-04-01
8663,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,241,D,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to promote care which enhanced the dignity for one (1) of forty-two (42) residents. This resident's fingernails were not groomed as he wanted them groomed. The resident's fingernails were long, jagged and had debris underneath. Resident identifier: #78. Facility census: 76. Findings include: a) Resident #78 On 01/05/12 at 9:30 a.m., observation of Resident #78 revealed he had long, jagged, and dirty fingernails. He said a physician came in to trim his toenails, but no one had trimmed his fingernails lately. The resident had right sided [MEDICAL CONDITION] which affected his right hand and arm. This made him dependent upon staff for things such as nail care. On 01/09/12, at approximately 11:30 a.m., Employee #92 (a licensed practical nurse) was informed the resident's fingernails needed trimmed. On 01/10/12 the resident's fingernails were observed and appeared clean and trimmed.",2016-04-01
8664,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,242,D,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview and staff interview, the facility failed to assure one (1) of forty-two (42) residents was afforded the opportunity to make choices about an aspect of his life that was significant to him. The resident complained about not having any personal spending money to buy things such as soda. He indicated he had informed the facility that he had no money and that this made him upset and angry. The resident had capacity to make decisions and had informed the facility he wanted access to his personal needs allowance which was allotted by Medicaid. The facility did not act upon the resident's request, or provide the resident assistance in getting his money. Resident identifier: #78. Facility census: 76. Findings include: a) Resident #78 Medical record review, conducted on the morning of 01/05/12, revealed this resident was admitted to the facility on [DATE]. On the afternoon of 01/05/12, during an interview with the resident, he indicated his brother handled all of his financial affairs. He said this worked out ok except his brother did not bring any money to him for personal needs. He indicated he had to call his brother and request items such as snacks. He said this bothered him and he would like to have his own money so he did not always have to call and ask his brother for things. On 01/05/12, at approximately 3:00 p.m., the business office manager (Employee #63) verified Resident #78 did not have a trust account set up by the facility. He produced a document showing the resident had declined to have a savings / trust account set up at the time of admission. Employee #63 also provided a copy of the resident's determination of medical capacity. This document, dated 04/21/10, revealed the resident had capacity to make medical decisions. Employee #63 said the facility did not have a copy of the financial power of attorney document. Employee #63 stated the resident had asked him to contact his brother in the past, and have money brought to the facility. He said the resident's brother had never brought any money for the resident's personal spending needs. The resident verified his brother had not brought any money and also said he had asked the office manager for assistance in this matter. On 01/05/12, at approximately 3:30 p.m., Employee #63 went to the resident's room and talked with him about this issue. Resident #78 told Employee #63 he would like to have money to buy things like soda. He wanted Pepsi or orange soda. The office manager told the resident he would personally bring soda to him the next day. On 01/09/12, at approximately 10:00 a.m., a nursing assistant, Employee #42, indicated she had brought Pepsi in for the resident on Sunday. She said he loved soda. On 01/10/12, at approximately 2:00 p.m., Employee #63 provided a copy of the general power of attorney document which listed Resident #78's brother as his general power of attorney. The general power of attorney afforded the brother the right to handle the resident's personal financial affairs. Employee #63 said Resident #78's brother had brought $50 for the resident on 01/10/12, and said he would start doing this on a regular basis. The facility did not provide the resident assistance in having personal spending money, until brought to the attention of the facility during the survey.",2016-04-01
8665,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,246,D,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to assure personal toiletry items were kept within reach for independent use for one (1) of forty-two (42) residents. Resident #78 did not have sufficient oral hygiene supplies for brushing his teeth. Resident identifier: #78. Facility census: 76. Findings include: a) Resident #78 On the morning of 01/04/12, during an interview, Resident #78 said he did not have a toothbrush or toothpaste. He said he had some bottom teeth, but they were not brushed every day. He said staff normally assisted him with oral hygiene about once a week. The resident had [MEDICAL CONDITION] affecting his right side. His night stand was next to his bed on his left side. He was able to access the night stand with his left hand. On 01/10/12, at approximately 2:00 p.m., a nursing assistant (NA), Employee #6, came into the resident's room and looked for his oral hygiene supplies. A tube of unopened toothpaste was in the drawer of the night stand. Employee #6 looked in other areas of the room and could not find any other supplies, such as a toothbrush or an emesis basin. Employee #70, a QA came in later with a toothbrush and emesis basin, and asked where he should put them. The resident requested Employee #70 put the supplies in the night stand drawer. He said he could brush his own teeth if the supplies were kept in the night stand.",2016-04-01
8666,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,253,E,0,1,46GB11,"Based on observations and staff interview, it was determined the facility had not assured the environment and condition of the furnishings were maintained in a sanitary and orderly manner. There were doors to resident bathrooms that had scuffs and scratches, furniture in common dining areas was in need of repair, a bathroom sink leaking, paint was peeling and chipped, and doors to the lounge area and central bath had deep scrapes and gouges in the wood. These environmental issues made the areas unsightly, as well as not easily cleanable. These issues were evident in twenty-two (22) resident rooms, doors to the central bath, and the resident lounge between the 100 and 200 hallways. Room numbers included: 102, 300, 315, 207, 212, 206, 313, 203, 113, 308, 314, 209, 305, 100, 215, 110, 204, 112, 208, 213, 200, and 212. This practice had the potential to affect more than an isolated number of residents. Facility Census: 76 Findings include: a) Rooms 102, 300, 315, 207, 212, 206, 313, 203, 113, 308, 314, 209, 305, 100, 215, 110, 204, 112, 208, 213, 200, and 212 Observations during the stage I interviews and tour of the facility revealed doors to resident rooms and bathrooms had scratches and gouges. Rooms had peeling paint, walls had holes in them, and chipped paint was observed on doorframes. b) Observations, on 01/11/12 at mid-morning, revealed there were chairs in the dining rooms with ripped and / or torn upholstery. The wooden legs of the chairs were scratched and / or in other disrepair. In the central shower area, a shower bed had a vinyl cover that was torn around the button areas. c) Room 308 had a leaking sink and a strong urine odor d) During the afternoon of 01/18/12, these environmental concerns were discussed with the administrator. .",2016-04-01
8667,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,279,E,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to develop a comprehensive care plan to address problems and needs for four (4) of forty-two (42) Stage II sampled residents. Resident #29 did not have a care plan to address her contractures and services needed to prevent further complications. Resident #73 did not have a care plan to address her dental needs. Resident #19 did not have a care plan to address the special care needed for her [DIAGNOSES REDACTED]. (Mayo Clinic April 9, 2011)). Resident #10 did not have a care plan to address her refusal of laboratory services. Failure to identify the needs and services to be furnished through the care planning process had the potential to result in a failure to provide optimum resident care. Resident identifiers: #29, #73, #19, and #10. Facility Census: 76. Findings Include: a) Resident #29 Resident #29 was admitted to the facility on [DATE] with severe joint contractures to all extremities. She received occupational therapy (OT) for management of her contractures. When she was discharged from OT, on 02/25/11, she was referred to the restorative nursing program for bilateral upper extremity and lower extremity passive range of motion exercises for fifteen (15) minutes a day six (6) days a week. This resident was transferred to the hospital, on 04/02/11, and was readmitted to the nursing home on 04/12/11. She was screened by therapy when she returned. It was determined she had an existing deficit, but there had not been a change in function, so she was not treated at that time in therapy. There was no evidence her care plan, which was established prior to her hospitalization , provided for the passive range of motion exercises to be continued after she was readmitted from the hospital. During an interview with the minimum data set (MDS) coordinator, Employee #19, on 01/10/12 at 3:30 p.m., it was verified the resident did not have a care plan to address her positioning or range of motion needs. Employee #19 verified this had been on the resident's care plan prior to her hospitalization in April 2011. However, when she returned on 04/12/2011, the care plan was revised with no plans for treatment or interventions to address the resident's contractures included. b) Resident #73 The comprehensive minimum data set assessment (MDS) assessment, dated 08/26/2011, was reviewed. Section V, in the care area assessment (CAA) note, indicated this resident had dentures. The resident was observed at 10:00 a.m. on 01/05/11. It was noted she did not have dentures in her mouth at that time. She was observed again at meal time, at 12:00 p.m. on 01/05/11. She had a pureed diet and was eating, but again she did not have dentures in her mouth. Resident #73 was observed, on 01/09/11 at 2:30 p.m., having her snack. Employee #32, a nursing assistant, was assisting her and was feeding her a nutritional shake. Employee #32 was questioned, at that time, about the resident's dentures. She stated that she had been off for a few months and the resident wore them before she left, but she had not seen them since she returned to work. An interview was conducted, at 6:00 p.m. on 010/9/11, with a licensed practical nurse, Employee #96. She stated she was the nurse for this resident. The nurse confirmed the resident wore dentures. She searched the resident's drawers in her room and her bedside night stand. There were no dentures located in the resident's room. Employee #96 stated she was not sure what happened to the dentures. She verified the resident did not have them in her mouth and was eating dinner at that time. At 6:15 p.m., the nurse reported she had found the resident's dentures. She stated they did not fit the resident very well. The nurse stated the facility was going to call and have the dentures fixed because they were too large. The medical record contained no evidence this resident's dentures did not fit properly or that her dentures were missing. Her dental CAA note indicated she had dentures, but stated there was no problem. There was no care plan relative to the resident's ill-fitting dentures. c) Resident #19 Review of the facility's care plan for Resident #19 found no identification of the resident's [DIAGNOSES REDACTED].#19 suffered from vision impairment due to the disease. The facility failed to address the [DIAGNOSES REDACTED]. Further review of the medical record found, during a hospital stay on 11/01/11, the physician noted the following: She has had multiple procedures on both lids due to Stevens-Johnso[DIAGNOSES REDACTED] related to cicatricial [MEDICAL CONDITION] (scarring of the conjunctiva), which happened 11 or [AGE] years ago. She is status [REDACTED]. The right eye lid remains affected by chronic Stevens-Johnson related changes. This finding was addressed with Employee #55, at 8:30 a.m. on 01/10/12. She stated, We are looking that up right now. d) Resident #10 Review of this resident's physician's orders [REDACTED].#10 was ordered a basic metabolic profile (BMP) every four (4) months and a complete blood count (CBC) every six (6) months. Review of the medical record found no laboratory services. Further review of the medical record found the following nursing documentation entries: -- 06/08/11 at 536 -- Resident cont (continues) to refuse to let staff obtain routine schedule labs after several attempts made. Will continue to keep trying to obtain. -- 06/22/11 at 14:20 -- Resident refuses to let staff obtain labs after several attempts made. Will continue to keep trying to obtain. -- 07/22/11 at 12:39 -- Resident refuses to let staff obtain routine labs after several attempts made per staff. Will continue to keep trying to obtain. -- 07/27/11 at 13:27 -- Resident cont to refuse to let staff obtain routine schedule labs after several attempts made per staff. Resident states 'you are not getting any of my blood'. -- 07/29/11 at 09:34 -- Resident cont to refuse to let staff obtain labs after several attempts made. Will continue to keep trying to obtain. -- 08/04/11 at 13:12 -- Resident continues to refuse to let staff obtain labs after several attempts made per staff. will continue to keep trying to obtain. -- 08/12/11 at 12:13 -- Resident continues to refuse to let staff obtain routine labs after several attempt made per staff. Will cont to keep trying to obtain. -- schedule labs after several attempts made per staff. Will continue to keep trying to obtain. -- 09/08/11 at 11:37 -- Resident continues to refuse to let staff obtain routine schedule labs after several attempts made per staff. Will continue to keep trying to obtain. Further review of the care plan found no indication of a problem with laboratory refusals for Resident #10. An interview, conducted on the afternoon of 01/09/12, with Employee #74, an MDS employee, confirmed the facility had the refusals care planned the prior year, but failed to identify the problem in the current care plan.",2016-04-01
8668,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,280,D,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on care plan review, medical record review, and staff interview, the facility failed to assure three (3) of forty-two (42) residents had care plans that were evaluated and updated as the residents' needs changed. Resident #78's care plan had not been revised to reflect his ability to remove his personal alarm which was used as a way to alert staff the resident had gotten up and could potentially fall. Resident #47's care plan was not updated after he received dentures. Resident #29's care plan was not updated after a urinary catheter was removed. Resident identifiers: #87, #47, and #29. Facility census: 76. Findings include: a) Resident #87 Care plan review for Resident #87, conducted on 01/09/12 at approximately 1:00 p.m., revealed the following problem, Potential for injury/falls R/T (related to) - History of falls- poor safety awareness - Attempts to transfer without assistance- [MEDICAL CONDITION] drug use. The care plan was initiated on 03/30/11. The interventions listed did not mention the resident's ability to dismantle/turn off his personal tab alarm. The tab alarm was placed on the resident's bed for safety. This intervention section had been revised on 08/05/11. Medical record review revealed Resident #87 sustained a fall, on 12/19/11 at 5:14 p.m. The documentation stated, His alarm was sounding in room, sat on floor on buttocks; hit his head, laceration to back of head. Went out to hospital and they put staples in his head. W/C (wheelchair) alarm noted to not be intact. Resident states he removed the alarm. On 01/10/12 at 10:22 a.m.,. the director of nursing (Employee #55) agreed the resident did have tendencies to remove or turn off his alarm. She agreed this element needed added to the resident's care plan. b) Resident #47 Review of the care plan for Resident #47 revealed the problem, Alteration in nutritional status r/t (related to) edentulous. The interventions included: -Appetite stimulants per orders - Diet: Regular - Mighty shakes 4 ounces/200 cal/ each at 10 am, PM, and PM for nutritional supplement - Monitor for any difficulty chewing, report to MD/Nursing. - Oral care per resident, staff assist as needed. - Weekly weights to monitor weight status-notify MD of significant changes to weight status During an interview with Employee #63, on 01/11/12, the business office manager, related to the resident's dental status, it was identified that Resident #47 had obtained dentures several months ago .Employee #63 stated, That's not true she has dentures because I made the appointment, they just haven't updated her care plan. c) Resident # 29 During a review of Resident #29's plan of care, it was noted there was an intervention that stated, catheter care q (every) shift and PRN (as needed). This resident was observed, on 01/09/2012 at 10:00 a.m. It was noted that she did not have an indwelling catheter. The nursing assistant, Employee #32, verified there was no indwelling catheter present and that it had been removed a few weeks ago. The treatment nurse (Employee # 41) was interviewed, on 1/9/2011 at 2:00 p.m. She verified the catheter had been discontinued on 12/15/2011 because it frequently came out, so the physician ordered to keep it out. At that time, it was verified that the care plan intervention that instructed the staff to provide catheter care should have been revised and removed from the resident's care plan.",2016-04-01
8669,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,313,D,0,1,46GB11,"Based on resident interview, observation, medical record review, and staff interview, the facility failed to assure one (1) of forty-two (42) sampled residents received assistance with her hearing devices. The resident had hearing aids, but staff failed to ensure the hearing aids were operational, and failed to provide the resident assistance in using them. Resident identifier: #19. Facility census: 76. Findings include: a) Resident #19 During an interview with Resident #19, the evening of 01/03/12, it was identified the resident had difficulty hearing the interview questions. Resident #19 stated, I cannot hear anything you are saying. On the morning of 01/04/12, an unidentified nursing assistant (NA) was asked if the resident had hearing aids. The NA stated, She had them, but I think something was wrong with the batteries. Resident #19 was observed on three (3) other occasions, after 01/03/12, without her hearing devices in place. Review of the care plan for Resident #19 found an intervention regarding the hearing aid, Assure resident is wearing hearing aid before engaging in conversation. This intervention was dated 11/23/11. The observation of the resident's difficulty in hearing was reported to the director of nursing, Employee #55, at 8:30 a.m. on 01/10/12. During the afternoon of 01/10/12, the DON reported, She has hearing aids - they were in her drawer.",2016-04-01
8670,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,318,D,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to provide appropriate treatment and services for a resident with severe contractures to prevent further decline in range of motion (ROM). Resident #29 received occupational therapy (OT) services, which included passive range of motion and joint mobility, to her extremities. After she completed her treatment with OT, she was referred to restorative nursing for passive range of motion (PROM). The resident experienced was hospitalized for [REDACTED]. When she returned from the hospital, there was no evidence the resident received range of motion services or treatment for [REDACTED]. Resident identifier: #29. Facility Census: 76. Findings Include: a) Resident # 29 Resident #29 was admitted to the facility on [DATE] with severe joint contractures to all extremities. She was provided OT for management of these contractures. When she was discharged from therapy on 02/25/2011, she was referred to the restorative nursing program for bilateral upper extremity and lower extremity passive range of motion exercises for fifteen (15) minutes a day six (6) days a week. This resident was transferred to the hospital on [DATE], and was readmitted to the facility on [DATE]. She was screened by therapy when she returned. It was determined she had an existing deficit, but there had not been a change in function. She was not treated again at that time by therapy. There was no evidence her care plan, which was established prior to her hospitalization , ensured the passive range of motion exercises were continued after she was readmitted . The restorative nursing assistant (Employee #15) was interviewed at 2:00 p.m. on 01/10/2012. Employee #15 verified she was treating this resident and providing passive range of motion to her extremities prior to the resident's hospitalization . Employee #15 stated when the resident returned from the hospital, on 04/12/2011, she did not receive an order to treat the resident; therefore, the resident was no longer receiving restorative nursing services. An interview was conducted with the occupational therapy (OT) assistant (Employee #100), at 2:30 p.m. on 01/11/2012. She verified this resident had received treatment for [REDACTED]. Employee #100 stated when the resident was transferred to the hospital and returned to the facility, therapy did not pick her up. Since the resident was not picked up by therapy services, there was no order written for restorative nursing services or any therapy related services. Employee #100 was asked if the resident needed range of motion for her contractures and she stated yes. She also said the resident's contractures were severe and would not get better; however she needed range of motion and proper positioning to prevent further complications. An interview with the minimum data set (MDS) nurse (Employee #19), on 01/10/12 at 3:30 p.m., verified the resident did not have a care plan to address her positioning or range of motion needs. Employee #19 verified these services were on the resident's care plan prior to her hospitalization in April 2011. When the resident returned to the facility, on 04/12/2011, the care plan was revised, but no treatment or interventions to address the resident's contractures were incorporated into the revised care plan. Employee #19 verified there was no evidence this resident was receiving range of motion services.",2016-04-01
8671,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,329,D,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** unecessary drug regimen review revealed drug regimen's were missing from the following months (September, October, November and December 2011. The medication review also revealed the resident was suppose to have a lipid panel in 09/12 no communication from pharmacist for drug regimen review conducted on 12/27/11 & 11/28/11. #35 Michale Coleman - Had not recieved a reduction of his [MEDICATION NAME] for a year. #78 Paul Blackburn Pharmacy review not done. No labs could be found related to liver function testing and accurate [MEDICATION NAME] levels. There was only one pharmacy review on [MEDICATION NAME] and that was in January of 2011. labs were not obtained as orderd.",2016-04-01
8672,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,356,B,0,1,46GB11,"Based on observations, review of the nurse staff posting and staff interview, the facility failed to ensure they were in compliance with the requirements set forth by the Center for Medicare and Medicaid Services (CMS) in relation to nurse staffing information. The facility was completing the staff posting in advance, rather than at the beginning of each shift as required. This practice had the potential to affect more than an isolated number of both residents and other interested individuals such as family members or visitors. Facility census: 76. Findings include: a) On 01/03/12, at approximately 4:30 p.m., an observation of the daily staffing sheet revealed the facility had the number of licensed practical nurses and registered nurses for night shift already filled in and counted. On 01/09/12, at approximately 11:00 a.m., a second observation of the daily staffing sheet revealed it had the wrong date listed and had the number of licensed and registered nurses had been filled in for day, evening, and night shifts. On 01/09/12, at approximately 12:00 p.m., the director of nursing (Employee #55) said Employee #89 (licensed practical nurse) took care of the daily staffing post and would answer any questions related to the issue. On 01/09/12, at approximately 1:00 p.m., Employee #89 confirmed she was responsible for the daily staffing posting. She stated she assigned another staff member to fill in the number and hours scheduled for licensed and registered nurses each day. Employee #89 indicated she would discontinue having staff fill out the sheet for the entire day, and instead, fill in the numbers at the beginning of each shift. b) The posting of staff was observed on 01/10/12. Noted on the bottom of this posting was Required staffing is 2.25 hours. This statement was misleading to the public because this is not the required staffing level, but the minimal staffing level required by the State licensure rule. The required staffing is the amount of staff necessary to meet the needs of the residents as described in their plan of care. The administrator was made aware of this statement, at 4:30 p.m. on 01/11/12. It was later verified this erroneous statement was removed from the posting.",2016-04-01
8673,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,371,F,0,1,46GB11,"Based on dietary observations and staff interview, dishware was not stored in a manner that promoted sanitary conditions. Stored plates were discovered to have water between them when food was being served on the tray line. This practice created a medium for bacterial growth resulting in a potential contamination of the dishware. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 76 Findings include: a) While observing meal service, at lunch on 01/09/12, plates were observed stored wet with moisture between them. As these were retrieved from the lowerator for use at the meal, some plates were observed wet. This practice had the potential to allow bacterial grow in the moist environment. The consultant dietitian was present at the time of the observation and verified wet dishes were present. The Food Code, section 4-901.11, requires equipment and utensils, after cleaning and sanitizing, be air dried or used after adequate draining. Wet storage, particularly when items are stacked on top of each other while wet, creates a medium for bacterial growth.",2016-04-01
8674,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,428,D,0,1,46GB11,"Based on record review and staff interview, the facility failed to ensure a drug regimen review was completed monthly by the consultant pharmacist for one (1) of forty-two (42) Stage 2 sampled residents. This resident had a monthly review on 01/24/11, but no reviews for the remaining months in 2011. Resident identifier: #35. Facility census: 76 a) Resident #35 Review of the facility's drug regimen reviews for Resident #35 revealed a drug regimen review dated 01/24/11. No other drug regimen reviews were found for this resident for the eleven (11) other months in 2011. During an interview, on 01/11/12, Employee #74 verified the facility could find no evidence the pharmacist conducted a drug regimen review for this resident after 01/24/11. unecessary drug regimen review revealed drug regimen's were missing from the following months (September, October, November and December 2011. The medication review also revealed the resident was suppose to have a lipid panel in 09/12 no communication from pharmacist for drug regimen review conducted on 12/27/11 & 11/28/11.",2016-04-01
8675,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,441,E,0,1,46GB11,"Based on review of the facility's infection control program, medical record review of residents with Escherichia coli (E-coli), and staff interview, the facility failed to implement an effective infection control program which identified the probable cause of a number of E-coli infections, and failed to develop a plan to prevent the spread of E-coli infections in the facility. This practice had the potential to affect more than a limited number of residents. Facility census: 76. Findings include: a) Review of the facility's infection control tracking form revealed nineteen (19) residents for which E-coli had been identified as the cause of urinary tract infections from 07/2011 through 12/28/11. The list included four (4) residents with indwelling Foley catheters and one (1) resident with a suprapubic catheter. Review of the infection control program found no in-service records related to the prevention of urinary tract infections associated with E-coli. On 01/10/12 at 3:09 p.m., the infection control nurse, Employee #93, stated, I did not focus on E-coli. I was just looking at what I needed to do for isolation measures. She further stated, I did not realize five (5) of the residents had catheters. When asked if she had provided in-services for nursing personnel related to E-coli infections associated with catheters, she stated, No. The facility failed to develop, implement, and maintain an effective infection prevention and control program, regarding the E-coli, to prevent, recognize, and control, to the extent possible, the onset and spread of this infection within the facility.",2016-04-01
8676,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,504,D,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain physician ordered laboratory services for one (1) of forty-two (42) Stage 2 sample residents. A resident was receiving medications for which liver function tests were indicated. The facility had not ensured liver function tests were obtained as ordered by the physician. Resident identifier: #35. Facility census: 76. Findings include: a) Resident #35 Review of this resident's medical record identified Resident #35 was ordered a liver function test every three (3) months. This was because the resident received [MEDICATION NAME] 120 milligrams per day and [MEDICATION NAME] for high cholesterol. Review of the medical record found only one (1) laboratory result for the liver function test, which was obtained on 06/17/11. During an interview with Employee #74, a minimum data set employee, on 01/11/12 at 9:53 a.m., she stated, This is the only one we have. She further stated, It was ordered in September, but we did not obtain it. It was also ordered in November, but we didn't get it then either. A liver function test was obtained for the resident on 01/12/12, after the failure to obtain the ordered test was brought to the facility's attention during the survey.",2016-04-01
8677,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,514,D,0,1,46GB11,"Based on resident interview, medical record review and staff interview, the facility failed to ensure the clinical record for one (1) of forty-two (42) Stage 2 residents was maintained in accordance with accepted professional standards. The medical record did not contain complete and accurate information for activities of daily living (bathing / showering). Resident identifier: #78. Facility census: 76. Findings include: a) Resident #78 On 01/05/12 at 8:52 a.m., Resident #78 said he had gone for several days without a shower, and he wanted a shower every day. Employee #89 (licensed practical nurse) indicated she supervised the restorative nursing program. She provided a copy of the resident's shower / bathing documentation for the month of December 2011. Employee #89 said the facility's computer system did not allow for the nurse aide to document whether a shower or a bath was given. The system the facility used did not allow for accurate documentation, as it did not allow for identification of whether a shower or a bath had been given. This was of particular concern when the resident stated he did not have a shower for days and he wanted a shower daily. There was no means to evaluate whether, and / or when, the resident was provided a shower as opposed to a bath.",2016-04-01
8678,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,520,E,0,1,46GB11,"Based on review of the facility's infection control program, quality assurance committee information, and staff interview, the quality assessment and assurance committee failed to identify and correct infection control problems and environmental issues. This practice had the potential to affect more than a limited number of residents. Facility census: 76. Findings include: a) Infection Control Program Review of the facility's infection control tracking form revealed nineteen (19) residents with E-coli identified as the cause of urinary tract infections from 07/2011 through 12/28/11. The list included four (4) residents with indwelling Foley catheters and one (1) with a suprapubic catheter. Review of the infection control program found no in-service records related to the prevention of urinary tract infections associated with E-coli. On 01/10/12 at 3:09 p.m., the infection control nurse, Employee #93, stated, I did not focus on E-Coli. I was just looking at what I needed to do for isolation measures. She further stated, I did not realize five (5) of the residents had catheters. When asked if she had provided in-services for nursing personnel related to E-Coli infections associated with catheters, she stated, No. On 01/11/12 at 2:30 p.m., the director of nursing (Employee #55) was asked if she had any evidence the quality assurance committee had addressed the more current urinary tract infections in the facility. Employee #55 provided information for 01/24/11. This information noted the committee had discussed, in general, urinary tract infections, but not urinary infections with E-coli and /or the E-coli infections which were associated with catheter use. The findings discussed in the meeting, dated 01/24/11, were issues related to October 2010, November 2010, and December 2010. Employee #55 provided no quality assurance information which verified the committee was aware and / or had an action plan regarding the facility's most current nineteen (19) urinary tract infections as described above. b) Environment The facility had not ensured the environment and condition of the furnishings were maintained in a sanitary and orderly manner. There were doors to resident bathrooms that had scuffs and scratches, furniture in common dining areas was in need of repair, a bathroom sink was leaking, paint was peeling and chipped, doors to the lounge area and central bath had deep scrapes and gouges in the wood. These environmental issues made the areas unsightly, as well as not easily cleanable. These issues were evident in twenty-two (22) resident rooms ( Room numbers included: 300, 102, 315, 207, 212, 206, 313, 203, 113, 308, 314, 209, 305, 100, 215, 110, 204, 112, 208, 213, 200, and 212), doors to the central bath, and the resident lounge between the 100 and 200 hallways. A discussion was held with the consultant maintenance / housekeeping staff from a sister facility, at 2:25 p.m. on 01/11/12. At that time, it was revealed there had not been a specific time planned to implement environmental repairs. She indicated environmental issues were discussed at quality assurance meetings, but no action plan regarding timetables for repairs and / or replacement of damaged furnishings had been established.",2016-04-01
8825,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2013-03-12,371,F,1,0,8SQC11,"Based on observation and staff interview, it was found sanitation issues were evident in the dietary department. Equipment needed repaired/replaced, walls and doors needed cleaned and repaired, equipment was in need of cleaning and milk cartons were stored covered in ice which was not a sanitary method. This practice had the potential to affect all residents as all residents were served food from this central location. Findings include: Upon observations in the dietary department, on 03/10/13 at 5:00 p.m., the following items were noted: a) A home-type freezer was found to have the interior lining broken with the insulation visible. b) Milk cartons were placed in a pan with ice completely covering the cartons. This could lead to possible cross contamination as the ice may be contaminated and then contaminate the opening of the carton from which an individual would drink. c) The lids of bins which contain flour and sugar had food debris spilled on them and were in need of cleaning d) The hand sink in the dishwashing area had caulking that was chipped and in need of repair. It was not easily cleanable. e) The inside of doors that entered the kitchen from the hallway were noted to have scrapes and gouge in them and therefore not easily cleanable. All of these issues were discussed with the dietary director of the sister facility, Employee #83, who was available for assistance in the absence of the facility's dietary manager. This occurred on 03/11/13 in the afternoon.",2016-03-01
8826,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2013-03-12,372,F,1,0,8SQC11,"Based on observation and staff interview, it was determined the facility had not ensured garbage and refuse were disposed of in a manner to ensure waste was properly contained and to prevent the harborage and feeding of pests. Dumpster lids were found to be left open and food items were exposed which had the potential to attract vermin. This practice had the potential to affect all residents residing in the facility. Findings include: a) Upon entering the facility, on 03/10/13 at 4:45 p.m., it was noted that the dumpster lids were open. This did not ensure waste was properly contained in the dumpster. Birds were observed getting into the exposed bags of garbage and food items that were lying on the ground near the unit. .",2016-03-01
9880,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-05-09,156,C,1,0,SZNR11,". Based on record review and staff interview, the facility failed to ensure three (3) of three (3) resident's received the appropriate discharge notice, as required by the Centers for Medicare and Medicaid Services (CMS), after they were discharged from a Medicare skilled service. Resident #22, Resident #72, and Resident #39 were all discharged from Medicare Part A skilled services in April 2012. The facility did not issue one (1) of two (2) notices at the time Medicare Part A services ended. Facility census: 77. Findings include: a) Resident #22 This resident was discharged from Medicare Part A, on 04/21/12, due to no further skilled services being available for her. b) Resident #72 This resident was discharged from Medicare Part A, on 04/15/12, due to no further skilled services being available for her. c) Resident #39 This resident was discharged from Medicare Part A, on 04/26/12, due to a completion of antibiotic therapy. d) An interview with Employee #10 (business office manager), on 05/09/12 at 1:00 p.m., revealed these three (3) residents had received the Notice of Non Coverage, CMS form ( ). The generic notice (form ) simply informs the resident of their right to an expedited review of the service termination for coverage reasons. The facility must issue the skilled nursing advanced beneficiary notice to address the resident's potential liability for payment if they remain in the facility. The residents had not received the Skilled Nursing Advanced Beneficiary Notice (SNFABN). According to the business office manager, all three (3) residents remained in the facility under another payer source. The facility needed to give the three (3) residents both notices because all Medicare covered services were ending and the center intended to deliver non-covered care. The SNFABN is given because benefit days remain to inform the resident of potential financial liability. .",2015-08-01
9881,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-05-09,203,D,1,0,SZNR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a closed medical record review and staff interview, the facility failed to ensure two (2) of five (5) residents were provided with a written discharge notice thirty (30) days prior to their discharge date s. This notice must include the reason for discharge, the effective date, the location to which the resident was being discharged , the right to appeal, how to notify the ombudsman, and how to notify appropriate protection and advocacy agencies. Resident identifiers: #57 and #85. Facility census: 77. Findings include: a) Resident #57 The medical record review for Resident #57, conducted on 05/08/12, at approximately 1:00 p.m., revealed this eighty seven (87) year resident was admitted to the facility on [DATE]. The resident left the faciity on [DATE]. According to the medical record, she now resides in a personal care home. Medical record review revealed several social service and nursing notes, dating back to November 2011, reflecting the resident's desire to return home. The facility completed a pre admission screening (PAS) on the resident. A progress note, dated 05/01/12, stated, ""Resident is in process of discharge planning. She no longer qualifies for nursing home care. At this point plans will be for her to go to (name of personal care home). The ombudsman will be here on Wednesday 05/02/12 to meet with res. and her family. The son who is health care surrogate will not transport to new facility. He wants her transferred by ambulance. "" Another progress note, dated 05/04/12, stated, ""Resident d/c (discharged ) to a personal care home due to no longer being eligible for nursing home level of care. Her son has made all the financial needs for the transfer. "" On 05/09/12, at approximately 11:00 a.m., the former business office manager (Employee #65) and the medical records clerk (Employee #14) reviewed the resident's closed record. The record did not contain information indicating the health care surrogate was provided a thirty (30) day discharge notice as required. b) Resident #85 This resident was also discharged due to not meeting the PAS requirements for nursing home care. The facility initiated a PAS for Resident #85 on 10/26/11. She remained at the facility until her appeal was heard. She was discharged on [DATE]. Resident #85 had the Department of Health and Human Resources (DHHR) as her appointed guardian. The DHHR appealed the discharge decision, but there was no evidence a thirty (30) day written notice, containing the required information, was given. .",2015-08-01
10750,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,279,D,0,1,667111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to develop a plan of care to address the care and treatment of [REDACTED]. The staff caring for this resident was not aware she had a drug-resistant infection in her eyes and nares. There was no evidence that the facility had a plan to alert staff and visitors of special precautions needed with respect to having contact with the resident's body secretions. This affected one (1) of thirteen (13) sampled residents . Resident identifier: #32. Facility census: 75. Findings include: a) Resident #32 Review of Resident #32's medical record revealed she was admitted to the hospital on [DATE], for an altered level of consciousness. According to her hospital records, she had had a fever and drainage from her eyes, and she tested positive for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in her right eye and her nares. She was receiving antibiotics for her nares and her eyes and was still receiving this treatment when she came back to the nursing home. Observation of this resident revealed she was not in any type of isolation, and her care plan did not identify any special precautions to be taken when interacting with or caring for this resident. During an interview with the infection control nurse (Employee #26) on 06/24/09 at 3:00 p.m., she was made aware of the resident's infections. She confirmed this was missed when the resident returned from the hospital; the resident's infections were not record on the facility's infection control log, and no isolation precautions were initiated when she returned from the hospital. She also confirmed Resident #23 should have been placed in isolation. This resident's room was observed at 9:00 a.m. on 06/25/09. The nursing assistant was observed taking special precautions prior to entering the room to care for this resident. There was a sign placed on the door to see the nurse before entering the room. These precautions were not put into place until seven (7) days after the resident had returned from the hospital. .",2014-12-01
10751,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,328,D,0,1,667111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure Resident #72 received the proper respiratory care and treatment. Staff failed to utilize proper technique to administer a nebulizer treatment to a resident with a [MEDICAL CONDITION] (trach). Staff also did not ensure this resident's oxygen was administered in accordance with physician's orders [REDACTED]. Proper respiratory care and treatment was not provided for one (1) of thirteen (13) sampled residents. Resident identifier: #72. Facility census: 75. Findings include: a) Resident #72 1. During an observation of the medication administration for Resident #72 on 06/23/09, this resident was observed to have an order for [REDACTED].# 81) administered this treatment by holding a face mask over the resident's trach. Observation found the medicated aerosol coming out the sides of the mask, with very little actually going into [MEDICAL CONDITION]. The nurse, when questioned about the use of this mask, stated they have special tubing for the trach, but they were out and did not have the right ones available. The assistant director of nursing (ADON), when interviewed on 06/23/09, was asked to provide the facility's policy and procedure for administering a nebulizer treatment to a resident with a trach. The ADON provided a policy for administering hand-held nebulizer treatments but stated they did not have a policy for administering a nebulizer via a trach. The ADON reported they have a respiratory person who comes in and provides them with the equipment they need and shows them how to use it. She stated the facility does have special tubing and [MEDICAL CONDITION] to use for the residents with trachs. 2. Further observations of this resident, throughout the day on 06/23/09 and 06/24/09, revealed this resident did not use her oxygen during those days. The resident's O2 saturation, when checked, was at 98%. A review of the resident's medical record revealed [REDACTED].@ (at) four (4) liters per minute via [MEDICAL CONDITION] Mask Q (every) shift."" The nurse, when questioned about this ordered intervention, reported the resident did not like to wear it. There was no evidence in the resident's record to show the resident's refusal to use the oxygen as ordered had been addressed with the physician prior to this, and there was no evidence to show staff provided teaching regarding the importance of using her oxygen as ordered. A physician's orders [REDACTED]. 3. Observation of this resident's respiratory equipment found a suction machine on her night stand that was very dirty and had the plastic cover broken off of the gauge. The nurse (Employee #81) was made aware of this, and the machine was immediately replaced. .",2014-12-01
10752,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,333,D,0,1,667111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure residents were free from significant medication errors. The nurse was preparing to administer 60 mg of the anticoagulant medication [MEDICATION NAME], instead of the 45 mg dose ordered by the physician. Receiving too much of this medication could result in internal hemorrhaging. Significant medication errors were found for one (1) of ten (10) residents observed during medication pass. Resident identifier: #66. Facility census: 75. Finding include: a) Resident #66 During medication administration, observation found a nurse (Employee #81) preparing medications for Resident #66. Review of the labels found a pre-filled syringe of [MEDICATION NAME] 60 mg /0.6 ml. The directions on the medication label stated to administer 0.5 ml (50 mg) sub-Q ( subcutaneously) bid (twice a day). While the nurse was preparing her medications, surveyor observed Resident #66's Medication Administration Record [REDACTED]."" The nurse was observed to complete her preparation. As she was preparing to administer the medications to the resident, the surveyor intervened and asked the nurse to stop and double check the label against the MAR. The nurse then verified the dose she was preparing to administer was not correct. The nurse then calculated the correct dose and wasted the excess medication that was in the syringe. The nurse proceeded to tell the surveyor they had discussed this, but the [MEDICATION NAME] did not come from the pharmacy in the dose ordered. .",2014-12-01
10753,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,441,F,0,1,667111,"Based on a review of the facility's policies and procedures for infection control and isolation for residents with infections, observations of residents with infections, and staff interview, the facility failed to develop and implement an effective infection control program to prevent the potential spread of infections in the facility. The facility's policies and procedures were not periodically reviewed and revised to reflect changes in standards of practice, and the existing procedures were not consistently implemented to prevent the spread of infectious organisms. The facility's did not maintain a record of all residents with infections, including the infectious organism found and/or the type of isolation precaution to be used. The number of residents at the facility with facility-acquired (nosocomial) infections had increased, but there was no evidence to show the facility investigated this increase in nosocomial infections for the causative factors or implemented measures to prevent further incidents of residents contracting nosocomial infections. The absence of an effective infection control program placed all residents residing in the facility at risk of acquiring an infection. Facility census: 75. Findings include: a) Infection Control Program Review of the facility's infection control policies and procedures revealed the policies were not thorough and were not consistently implemented. The infection control policy (which did not contain an effective date) stated the purpose of the policy was to ensure the infection control program was effective for investigating, controlling, and preventing infections in order to provide a safe sanitary, and comfortable environment. The procedure for this stated the following: ""1. LPN (Licensed Practical Nurse) on duty will report any signs / symptoms of infection to the physician. Along with any other information requested. ""2. Obtain order for treatment. Check ER (emergency) box to see if medication ordered can be obtained. If not STAT medication to facility. ""3. Notify the responsible party of resident's condition and what is being done. ""4. Monitor resident frequently at least each shift for three (3) days. Report any change in condition to the physician and the POA (power of attorney). ""5. The Infection Contort nurse completes a monthly tracking and report sheet."" This was the entire policy on infection control. There was no evidence the facility's infection control program was periodically reviewed or revised to reflect current, nationally recognized standards of practice established by the Centers for Disease Control and Prevention (CDC) and/or the Association for Professionals in Infection Control and Epidemiology (APIC). The facility's policies did not include measures to assure the cause of an infection was investigated and appropriate transmission-based precautions were implemented to control the spread of the infectious organism. A review of the facility's isolation practices revealed the existing policies and procedures were not consistently implemented. (See also citation at F442.) For example: - Resident #32 returned from the hospital with methicillin-resistant Staphylococcus aureus (MRSA) in her eyes and nares. This resident was not added to the infection control log for tracking, analysis, and trending. She was not placed in any form of isolation, and precautions to prevent the spread of this infectious organism to others were not implemented. - Resident #26 was in isolation, and the sign on his door stated ""strict isolation"". This resident had MRSA in a wound on his heel, and the infectious wound drainage was contained in a dressing. The facility was serving his meals on paper plates utilizing disposable dinnerware and keeping his door closed, when the resident only required contact precautions. The facility's policies concerning the types of precautions to be used were unclear. The policy for contact precautions stated these precautions shall be used in addition to standard precautions for residents with specific infections that can be transmitted by direct and indirect contact. This policy indicated gloves should be worn when entering the room. Further review of the policies indicated standard precautions were to be used in the care of all residents, including residents with MRSA. According to the facility's policy, ""Isolation of residents with MRSA in long term care facility's (i.e. contact precautions) is generally not necessary."" During this survey, observation found residents were required to keep the corridor door shut with a sign on the door announcing strict isolation, and nursing assistants and housekeeping staff were directed to wear personal protective equipment (including gloves, masks, and gowns) even if they were not going to come in contact with the resident. According to facility policy, isolation trash and linen were to be handled in the same manner as all trash and linen in the facility, yet there were two (2) very large barrels in the room of one (1) resident in isolation for the containment of trash and linens due to this resident having MRSA. A review of the facility's infection control surveillance data found that, in the month of April 2009, there were ten (10) nosocomial infections in the facility on three (3) halls. In the month of May 2009, there were eighteen (18) residents with nosocomial infections on the 100 and 200 halls, and no data were available regarding residents on the 300 hall. The facility's total census at the time of this survey was seventy five (75). With eighteen (18) affected residents, twenty-four percent (24%) of the facility's census had nosocomial infections. These surveillance data were recorded on the infection control logs, but there was no evidence the facility investigated the cause of these infections (examples: possible transmission during wound care, catheter care, perineal care, the administration of eye drops, etc.). The assistant director of nursing (ADON - Employee #46), when interviewed about the facility's infection control program on the afternoon of 06/24/09, confirmed that what was provided to the survey team was all that was written. When questioned about the facility's isolation policies, the ADON acknowledged not knowing that Resident #32 had a MRSA infection and confirmed that isolation procedures were not always implemented as written. She stated they call the doctor and then do what the doctor tells them to do as far as isolation. .",2014-12-01
10754,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,226,C,0,1,667111,"Based on a review of the facility's policy titled ""reporting abuse"" and staff interview, the facility failed to ensure its ""reporting abuse"" policy addressed the identification, reporting, and prevention of resident neglect. This practice had the potential to affect all facility residents. Facility census: 75. Findings include: a) On 06/23/09 at approximately 10:00 a.m., the facility's policy titled ""reporting abuse"" was reviewed. The policy did not identify what constituted resident neglect, nor did it address how, when, or who would report such situations within the facility, and to what State agencies they would be reported outside of the facility. The policy also did not explain how the facility would prevent neglect from occurring. The policy basically only gave an understanding on what constituted abuse and how the facility would proceed with identifying, preventing, and reporting allegations involving abuse. The facility social worker and director of nurses both agreed the policy did not address allegations of resident neglect, including identification, reporting, and prevention. .",2014-12-01
10755,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,152,E,0,1,667111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, a review of the West Virginia Health Care Decisions Act, and staff interview, the facility failed to ensure, for three (3) of thirteen (13) sampled residents, a legal surrogate was appointed in accordance with State law for residents lacking the capacity to understand and make their own informed health care decisions. Determinations of incapacity were made solely based on a [DIAGNOSES REDACTED]. Resident identifiers: #50, #33, and #47. Facility census: 75. Findings include: a) Resident #50 On 06/24/09 at approximately 2:00 p.m., review of Resident #50's medical record revealed a physician's determination of capacity form indicating Resident #50 lacked the capacity to understand and make informed health care decisions. However, the cause of the incapacity had not been recorded on the form. b) Resident #47 On 06/23/09, review of Resident #47's medical record revealed a physician's determination of capacity form indicating Resident #47 lacked the capacity to understand and make informed health care decisions due to having a [DIAGNOSES REDACTED]. c) Resident #33 Review of Resident #33's medical record, on 06/23/09, revealed the physician determined she lacked the capacity to understand and make her own health care decisions; however, the cause of her incapacity was not recorded. d) According to '16-30-7. Determination of incapacity., ""(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. ""(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ""(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. .",2014-12-01
10756,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,465,F,0,1,667111,"Based on observation and staff interview, the facility failed to maintain an environment for residents that was in good repair. All but one (1) hallway had doors in need of repair, the surface of an isolation table was unclean and in poor repair, and Resident #58's room and nursing equipment were not maintained in a sanitary manner. Facility census: 75. Findings include: a) On 06/25/09 at approximately 10:00 a.m., a tour of the inside of the building revealed the corridor doors of resident rooms were scarred and had some type of substance on them. The administrator said the doors had holes that had been filled (but not finished), and the filler was the substance that had been noted. He agreed the doors were not in good condition and commented that they were replacing the doors one (1) at a time, and he hoped to have all of them replaced soon. b) An isolation table was also observed to be in poor repair on the 200 hallway. The table was beaten and scratched up and appeared dirty. c) Resident #58 Observation, during a tour of the facility on 06/25/09, revealed Resident #58's room contained a suction machine that was not clean. The wall area in this room was also dirty, with splashes that ran down the wall. d) On 06/25/09 at approximately 1:00 p.m., the administrator indicated he was unaware of the dirty equipment and condition of the walls in Resident #58's room as well as the soiled table on the 200 hallway. The administrator indicated the areas and equipment would be cleaned as soon as possible. .",2014-12-01
10757,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,309,D,0,1,667111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure one (1) of thirteen (13) sampled residents received medication in an amount as ordered by the treating physician. Resident identifier: #21. Facility census: 75. Findings include: a) Resident #21 During observations of the medication administration pass on 06/23/09 at 8:50 a.m., the nurse was monitored while preparing Resident #21's medications. The nurse was noted to place a [MEDICATION NAME] 325 mg (Iron) tablet into a plastic medication administration cup with her other medications. Review of the Medication Administration Record [REDACTED]. As the nurse locked her cart and prepared to enter the resident's room, she was asked to review the MAR. She agreed the resident should not be administered the [MEDICATION NAME] and discarded the medication. .",2014-12-01
10758,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,371,F,0,1,667111,"Based on observations and staff interview, the facility failed to ensure proper sanitation procedures were employed for manual warewashing, freezer units had internal thermometers to ensure food items were being stored at proper temperatures, and food (ice) was being handled with clean utensils when served. These practices have the potential to affect all residents, as all residents who consume food by oral means are served from this central location. Facility census: 75. Findings include: a) During the initial tour of the kitchen on the afternoon of 06/23/09, observation found the walk-in freezer did not contain an internal thermometer to ensure correct temperature levels were being maintained for safe storage of frozen foods. b) Also during the tour, observation found dietary staff had placed a sanitizer tablet in the water of the three-compartment sink for manual warewashing; the tablet had not dissolved. The surveyor questioned staff about the method used to sanitize, and the dietary staff indicated they used tablets that would dissolve in the water to the make the right concentration of sanitizer. Review of the manufacturer's directions for use of the tablets revealed staff needed to increase the amount of water in the sanitizing compartment of the three-compartment sink and use hot water to dissolve the tablets. The dietary manager and the consultant dietitian were present and instructed the staff member to add more water and use two (2) tablets, not one (1). Additionally, they directed the staff member to use hot water, not just warm water from the tap. c) During observations of the medication pass on 06/23/09 at 9:35 a.m., the nurse was observed to pour water (for a resident to take medications) from a clear plastic pitcher. Observation of the water pitcher noted the inner rim beneath the pitcher was coated with a black layer of grime. This same substance was present on the inner portion of the plastic handle. The nurse agreed the pitcher was not clean and stated she had not noticed it. She obtained a clean pitcher to complete her medication pass. .",2014-12-01
10759,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,492,D,0,1,667111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and review of the West Virginia Health Care Decisions Act, the facility failed to ensure the physician orders [REDACTED]. Resident identifiers: #26 and #77. Facility census: 75. Findings include: a) Resident #26 Review of the medical record found a POST form completed on [DATE]. Section A was documented the resident was to receive cardiopulmonary resuscitation (CPR) should he suffer cardiac or [MEDICAL CONDITION] arrest. Further review noted Section B directed the resident receive comfort measures. This section specifically states: ""Do not transfer to hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location."" The two (2) sections, as completed, conflicted with the resident's wishes to receive treatment to support cardiac and [MEDICAL CONDITION] function. The POST form did not comply with the West Virginia Health Care Decisions Act [DATE](b) which states, ""...in accordance with that person's wishes..."". b) Resident #77 The medical record of this female resident contained a POST form dated ""2/ /09"" (date was incomplete), which was not signed by either the resident or the resident's legal surrogate for health care decisions. This was discussed with the office manager on the afternoon of [DATE], who verified the form was incomplete and that there was not way to determine whether the directives otherwise noted on the form reflected the actual wishes of the resident. .",2014-12-01
10760,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,161,E,0,1,667112,"Based on a review of the facility's surety bond and staff interview, the facility failed to obtain an approval by the WV Office of Attorney General (AG) for the surety bond after the amount of the bond was increased. This practice has the potential to affect at least fifty-one (51) residents. Facility census: 77. Findings include: a) A review of the facility's surety bond revealed the facility had increased the amount of the bond from $20,000 to $40,000 to assure the security of the residents' personal funds. There was no evidence this new surety bond had been approved by the AG for sufficiency of form and amount, as required. The administrator verified, at 09/07/09 at 4:00 p.m., the bond with the new amount had not been approved by the AG's office. .",2014-12-01
10761,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,225,E,0,1,667112,"Based on a review of the facility's reported abuse investigations and staff interview, the facility failed to ensure an allegation of neglect was thoroughly investigated. Resident #78's family reported the resident had arrived at 2:00 p.m. on 08/22/09, and they reported to the nurse at 6:00 p.m. that no staff member had been in her room since she arrived. The report also stated an indwelling Foley urinary catheter bag had been put in the bed with the resident. During the investigation, a written statement by the nursing assistant providing care for the resident on 08/22/09 indicated the family told her a ""shake"" was also thrown in the corner of the sink and not given to the resident. A review of the investigation into allegations of neglect involving this resident revealed no evidence to reflect the allegations related to the nutritional supplement not being given and the Foley catheter bag laying in the resident's bed were further investigated. The investigation was not thorough for one (1) of three (3) allegations of neglect that were reported. Resident identifier: #78. Facility census: 77. Finding include: a) Resident #78 According to the facility's abuse reporting records, on 08/22/09, Resident #78's son came to the nurse and wanted to see the charge nurse. That nurse told him she was the charge nurse, and he asked her to come in the resident's room. When the nurse went in the room, he told her his mother (Resident #78) had arrived at the facility at 2:00 p.m. that day, and no staff member had turned her since she arrived and that a Foley catheter bag had been put in bed with the resident. This was at 6:00 p.m. on 08/22/09, and he wanted to make sure this did not happen again. This incident was reported to the State agencies including the nurse aide registry for the nursing assistant responsible for providing care to the resident at that time. A review of the facility's investigation found the family member told the nursing assistant there was a ""shake"" (nutritional supplement) for 2:00 p.m. that was ""thrown"" in the corner of the sink and not given to the resident. In this nursing assistant's written statement, she said she started her shift at 2:30 p.m. that day. There was no evidence the facility interviewed the caregiver who was there at 2:00 p.m. on 08/22/09, to investigated the allegations of the nutritional supplement not being given and the the Foley catheter bag laying on the resident's bed. The five-day follow-up report stated the nursing assistant had been retrained and inserviced on turning and repositioning of the resident, related to the allegation of not having turned her, but there was no evidence the other allegations (related to the nutritional supplement and the Foley catheter bag) were investigated. During an interview on 09/09/09 at 11:00 a.m., the social worker confirmed that not all of the allegations of neglect made by Resident #78's son were thoroughly investigated. .",2014-12-01
10762,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,508,D,0,1,667111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain radiology services in a timely manner as ordered by the treating physician for one (1) of thirteen (13) sampled residents. Resident identifier: #60. Facility census: 75. Findings include: a) Resident #60 Review of the medical record found a 02/19/09 physician's orders [REDACTED].-resistant Staphylococcus aureus (MRSA) had cleared. Review of the medical record found no evidence the facility had obtained the ordered radiology service for this resident. The director of nursing (DON) provided information which stated the CT would have been scheduled on 03/03/09. During an interview conducted on 06/25/09 at 9:15 a.m., the DON agreed staff should have either obtained the CT scan or called the physician. .",2014-12-01
10763,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-09-10,332,E,0,1,667112,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and a review of the manufacturer's instructions for administration, the facility failed to assure it was free of medication error rates of greater than 5%. The facility had a medication error rate of 12.5 %. Medications not administered in accordance with the physician's orders [REDACTED]. Additionally, a nurse prepared to administer the incorrect vitamins, and a resident was not instructed to rinse his mouth out with water following the administration of the [MEDICATION NAME] Diskus. There were forty (40) opportunities with a total of five (5) medication errors observed. Resident identifiers: #75, #6, #63, and #47. Facility census: 77. Findings include: a) Resident #75 During the medication pass observation on 09/09 2009 at 9:00 a.m., the nurse (Employee #15) administered medications to Resident #75, including a dose of medication from a bottle labeled [MEDICATION NAME] 500 mg. Review of physician orders [REDACTED]. The dose administered did not match the medication ordered by the physician. b) Resident #6 During the medication pass observation on 09/09 2009 at 9:15 a.m., Employee #15 administered medications to Resident #6, including a dose of medication from a bottle labeled [MEDICATION NAME] 500 mg. Review of physician orders [REDACTED]. The dose administered did not match the medication ordered by the physician. c) Resident #63 During the medication pass observation on 09/09/09 at 9:20 a.m., the nurse administered medications to Resident #63, including the inhalant [MEDICATION NAME]. The nurse administered the [MEDICATION NAME] discus and then closed the Diskus and put it back in the cart. The nurse failed to instruct the resident to rinse his mouth out with water and spit after the administration of this medication. The nurse, when questioned about rinsing out the resident's mouth, she stated she was not aware that they had to do this. A review of the instruction sheet provided with the medication found: ""After each dose, rinse your mouth with water and spit the water out. Do not swallow."" This medication was not administered according to the manufacturer's instructions. d) Resident #47 During the medication pass observation on 09/09/09 at 9:45 a.m., the nurse (Employee #83) administered medications to Resident #47, including a dose of medication from a bottle labeled [MEDICATION NAME] 500 mg. Review of physician orders [REDACTED]. The dose administered did not match the medication ordered by the physician. The nurse, when questioned about the [MEDICATION NAME] without Vitamin D, stated this was what the pharmacy sent and told them to administer when they called and told them they needed [MEDICATION NAME] with Vitamin D, and this was what they had been giving the residents. e) Resident #47 Employee #83 was observed preparing the medications for administration for Resident #47. She took out a vitamin from the bottle labeled ""Multi Vitamin with minerals"". When the nurse prepared to administer the medications, this nurse surveyor intervened and asked the nurse to check again to be sure this was the correct medication. The nurse checked the bottle's label against the resident's Medication Administration Record [REDACTED]."" She then obtained the other bottle of vitamins that did not contain minerals and administered a dose to the resident. .",2014-12-01
10764,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-09-10,520,F,0,1,667112,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on information gathered on a revisit through observation, record review, and staff interview, the facility failed to implement a plan of action to correct identified quality deficiencies. The facility failed to correct deficient practices in six (6) of the same areas after the facility submitted an acceptable plan of correction indicating these concerns would be resolved prior to the end of August 2009. Repeat deficiencies were found in the areas of protection of residents funds, abuse investigating and reporting, care planning, medication errors, infection control, and isolation. This practice has the potential to affect all of the residents in this facility. Facility census: 77. Findings include: a) The facility's plan of correction for the standard survey completed on 06/25/09 was reviewed; however, deficient practices remained within respect to the following: 1. The facility failed to obtain an approval by the WV Office of Attorney General (AG) for the surety bond after the amount of the bond was increased. This practice has the potential to affect at least fifty-one (51) residents. See citation at F161. 2. The facility failed to ensure an allegation of neglect was thoroughly investigated. The investigation was not thorough for one (1) of three (3) allegations of neglect that were reported. See citation at F225. 3. The facility failed to develop a plan of care to include the precautions to be taken during the care of residents who had a drug resistant infection. This was true for three (3) of three (3) residents reviewed who had a drug-resistant infection. See citation at F279. 4. The facility failed to administer a medication as ordered by the physician. This was a significant medication error affected one (1) of ten (10) sampled residents. See citation at F333. 5. The facility failed to implement an effective infection control program to prevent the potential spread of infections in the facility. The absence of an effective infection control program placed all residents in the facility at risk of acquiring an infection. See citation at F441. 6. The facility failed to implement transmission-based isolation precautions when indicated for residents with infections and failed to ensure residents were isolated according to the physician's orders [REDACTED]. See citation at F442. b) By virtue of the fact that repeat non-compliance was found on the on-site revisit completed on 09/10/09, the quality assurance committee failed to implement appropriate plans of action to correct identified quality deficiencies. .",2014-12-01
10765,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-11-18,514,B,0,1,667113,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to utilize the correct reporting forms for submitting initial and five (5) day follow-up reports for allegations of resident abuse / neglect to the State survey agency's Nursing Home Program; failed to incorporate all necessary data onto one easy-to-read form for infection control tracking; and failed to ensure a transcription error did not occur for one (1) of forty-three (43) observed medication administrations. Facility census: 73. Findings include: a) Review of the facility's abuse policy, on 11/17/09, revealed, on page 3 Item #5 ""Investigation and Reporting"", the facility's plan to send immediate fax reportings of allegations and five (5) day follow-up reports to the State survey agency's Nurse Aide Abuse Registry. Review of all the self-reported allegations and their respective investigations for September, October, and November 2009 revealed several were submitted using the Nurse Aide Abuse Registry's reporting forms for instances where a nursing assistant was not involved in the alleged event and the Nursing Home Program's reporting forms (which is a separate program within the same State survey agency) should have been used, as follows: 09/13/09 involving Resident #34; 09/20/09 involving Resident #69; 09/24/09 involving Resident #34; 09/25/09 involving Resident #2; 09/29/09 involving Resident #67; and 10/04/09 involving Resident #25. Five (5) of the above events were related to unknown perpetrators, and one (1) event (dated 09/13/09) was related to a licensed practical nurse. In all of the cases, no allegations of abuse or neglect were substantiated. During interview with the director of nursing on 11/18/09 at 9:00 a.m., the above findings were discussed, and she received a copy of the two-page Table 1 - Abuse / Neglect Reporting Requirements for WV Nursing Homes and Nursing Facilities revised August 2009. She stated the social worker completes and faxes the five (5) day follow-up reports for the facility. During interview with the social worker on the afternoon of 11/18/09, he stated he used the Nurse Aide Abuse Registry forms for submitting all reportable sent to the State survey agency (regardless of which program is responsible for reviewing and/or investigating the allegations); on the fax cover sheet, he would differentiate whether the report is to be sent to the Nursing Home Program or the Nurse Aide Abuse Registry, as they have the same fax numbers. These findings were again discussed at exit. As a result, the assistant director of nursing changed the policy at page 3 ""Investigation and Reporting"", to differentiate the reporting of allegations pertaining to only nursing assistants (to the nurse aide registry) from allegations that should be faxed to the State survey agency's long term care division. Also, the assistant director of nursing spoke her awareness now of the website where both programs' reporting forms can be located and downloaded for use. The director of nursing stated, at exit, that each nursing unit and the social worker now had the August 2009 revision for [MEDICATION NAME] on site for future reference. Correction of this component of the deficient practice was completed prior to exit. b) Review, on 11/17/09, of the infection control policies and procedures and of the Infection Control Tracking Form for logging resident infections for September, October and November 2009 revealed the Infection Control Tracking Form had a place for the room numbers, but no room numbers were written on the form. There was no place on the form to document the date for the re-cultures. Additionally, the form had a place for recording the results of the re-cultures, but the results were not always recorded. Interview with the infection control nurse, on 11/17/09 at 10:15 a.m., revealed she had a Daily Culture / Re-culture Monitoring form on the computer and was able to track and give answers for every question asked about the data on the current Infection Control Tracking Form (ICTF). Each Infection Control Tracking Form was differentiated by hall divisions (100, 200, 300, 400 halls), but she agreed that filling in the room numbers on the ICTF would be a good idea for tracking purposes, in the event residents changed rooms during the process. She spoke of plans to alter the form to include the re-culture dates and spoke agreement that completing the re-culture results (or recording why they did not require re-cultures) on the ICTF would be helpful to keep information in one easily observed location. The above findings were discussing during interview with the director of nursing 11/18/09 at 9:00 a.m., as well as the infection control nurse's plan to revise the form. The director of nursing spoke highly of the improvements in their infection control prevention, monitoring, and trending, and noted that numerous inservices in infection control issues have taken place in recent months. During exit these findings were discussed, and the infection control nurse presented a revised ICTF that now has a separate place to record room numbers and a separate place to record re-culture dates. Correction of this component of the deficient practice was completed prior to exit. c) Medication pass was observed with all medication nurses 11/17/09 on the 7:00 a.m. to 7:00 p.m. shift. Reconciliation of the medications, on 11/17/09 at approximately 4:30 p.m., revealed Resident #43 received [MEDICATION NAME] 0.1% one (1) drop to each eye during the medication pass at 8:40 a.m. on 11/17/09. Review of the original physician's orders [REDACTED]."" Review of the November 2009 monthly recapitulation of physician orders [REDACTED]."" Verification with a pharmacist revealed that Patinol only comes in a 0.1% strength solution; there is no [MEDICATION NAME] 2% solution. The medication nurse rechecked the bottle of Patinol that was used for Resident #43 this morning and agreed that it was Patinol 0.1%. During interview with the director of nursing on 11/18/09 at 9:00 a.m., she stated the pharmacy was supposed to notify nursing if there are any concerns or discrepancies in physician orders. At this point in time, she was not sure if the pharmacy notified nursing and nursing did not correct the order or if pharmacy failed to notify them. She stated an investigation will be forthcoming. She agreed that no harm occurred to Resident #43, as she got the correct medication in the correct dose at the correct time, but there was a transcription error. Review, on 11/18/09, of physician orders [REDACTED].",2014-12-01
11112,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2011-04-01,157,D,1,0,0DKH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, and staff interview, the facility failed to notify the legal representative of one (1) of three (3) sampled residents when she had been restrained to her bed without a physician's order. Resident identifier: #65. Facility census: 84. Findings include: a) Resident #65 Review of facility documents found that, on 03/10/11 at approximately 9:00 p.m., a quality assistant (QA - Employee #0) reported Resident #65's was restrained in her bed by a tightly tucked blanket / sheet. Review of Resident #65's medical record found no physician's order or care plan for the resident to be restrained in her bed by the use of tightly tucked sheets or blankets. Review of the facility's interview investigation, and interviews with facility staff and former staff conducted on 03/30/11, 03/31/11, and 04/01/11, confirmed the blanket / sheet on Resident #65's bed had been tightly tucked beneath her bed to the point that staff had to tear the blanket / sheet in order to free the resident. An interview with the director of nursing (DON), on the afternoon of 03/31/11, elicited that Resident #65's legal representative was not contacted about the incident nor informed that the resident had been restrained without a physician's order, until he came into the facility on [DATE]. The DON stated the legal representative relayed that a woman had called him and told him Resident #65 had been found tied to her bed. .",2014-08-01
11113,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2011-04-01,221,D,1,0,0DKH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, staff interviews, and review of the State Operations Manual (Appendix PP - Guidance to Surveyors), the facility failed to assure one (1) of three (3) sampled residents was free from physical restraints imposed for the purpose of convenience and not required to treat the resident's medical symptoms. Resident identifier: #65. Facility census: 84. Findings include: a) Resident #65 Review of facility documents found a former quality aide (QA - Employee #0) reported Resident #65 had been restrained in her bed by the use a of tightly tucked blanket / sheet at approximately 9:00 p.m. on 03/10/11. Review of Resident #65's medical record found no evidence the treating physician ordered the resident to be restrained while in the bed. Further review of the medical record found a minimum data set (MDS) with an assessment reference date (ARD) of 01/17/11. Review of this MDS revealed this [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was assessed as having long and short term memory problems and difficulty focusing attention with disorganized thinking, and she displayed moderately impaired cognitive skills for daily decision making with noted delusions. She is always incontinent of bowel and bladder. She required one person physical assistance with bed mobility, transfers, dressing, eating, personal hygiene and total assistance with bathing. -- The following interviews were conducted with former and current staff: 1. Employee #0 (a QA) Employee #0 was interviewed at 9:59 a.m. on 04/01/11. She stated she was working the evening shift on 03/10/11 at approximately 9:00 p.m., when she walked past Resident #65's room and heard her call out ""Baby Doll"". Employee #0 stated she entered the resident's room to determine if the resident was trying to get up or had fallen. She noticed Resident #65 was lying on her back and was trying to raise her upper body but could only lift up about a foot. When she looked closer, she saw the resident's sheet and blanket was ""really tight"" across her abdomen. She reported this to Employee #65, a medical records clerk. 2. Employee #65 (medical records clerk) Employee #65 was interviewed at 3:19 p.m. on 03/30/11. She stated she worked late on the evening of 03/10/11 when, at about 9:30 p.m., Employee #0 approached her and told her she needed to check Resident #65, as the QA believed the resident was being restrained. Employee #65 went into Resident #65's room and noticed the resident was lying on her back on the bed. Employee #65 described walking over to the resident's bed and pulling on the blanket beneath her breast area, which appeared to be tight. She stated she was only able to move the blanket about an inch from the resident's body. She stated she reported the resident's condition to the charge nurse, a licensed practical nurse (LPN - Employee #93). 3. Employee #93 (an LPN) Employee #93 was interviewed at 8:45 a.m. on 03/31/11. She stated that, at approximately 9:15 p.m., Employee #65 requested her to come and look at Resident #65, that she was tied to her bed. Employee #93 described that, when she entered the resident's room, she noted a thin white blanket was tucked tightly under the resident's mattress. She left the room to get assistance from Employee #22, a certified nursing assistant (CNA). She stated both she and Employee #22 had to rip the blanket to get it off the resident. 4. Employee #4 (a QA) Employee #4 was interviewed at 4:43 p.m. on 03/30/11. She stated that, two or three days before 03/10/11, she and another QA were in Resident #65's room with a CNA (Employee #25). She stated Employee #25 showed them that the resident's sheet was tucked between the mattress and the bed frame. She relayed that Employee #25 stated, ""This is why (Resident #65) isn't getting up."" Employee #4 stated the QAs were required to watch Resident #65, because she would try to stand up / get up when she is in her bed and would fall. She stated it was really hard to pass ice and snacks and also have to watch this resident. 5. Employee #47 (the social worker) Employee #47, the social worker for the facility, was interviewed on the afternoon of 03/31/11. She stated she saw the blanket that had been removed from Resident #65's bed. She described two (2) jagged tears on two (2) of the corners of the resident's blanket. 6. Employee #25 (a CNA) Employee #25 was the CNA assigned to care for Resident #65 on the evening shift on 03/30/11. He was the only aide assigned to the resident's hallway. He was interviewed at 5:04 p.m. on 03/31/11. He denied restraining the resident by tightly tucking the blanket or sheet under the resident's mattress. 7. Employee #68 (a CNA) An interview with Employee #68 was conducted at 6:54 p.m. on 03/30/11. She stated that, on the evening shift on 03/30/11 after the 9:00 p.m. bedcheck, Employee #22 told them they were not to ""tie nobody up, restrain nobody, tie the covers or tuck them in until they can't move"". When Employee #68 asked Employee #22 why they were being told this, she stated Employee #22 informed her they had to rip the two (2) corners of the sheets to get Resident #65's covers loose. -- The facility obtained a statement from Employee #22, a CNA who worked night shift aide on 03/11/11. Her statement concurred that Resident #65's sheet was tucked tightly under the mattress. (This individual was not available to be interviewed by the surveyor.) -- Review of the State Operations Manual, Guidance to Surveyors, F221, found examples of restraints included, ""... Tucking in or using Velcro to hold a sheet, fabric, or clothing tightly so that a resident's movement is restricted..."". .",2014-08-01
11114,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2011-04-01,225,D,1,0,0DKH11,". Based on staff interview, review of the facility's abuse / neglect policies, and review of facility documents, the facility failed to ensure all allegations of abuse / neglect were immediately reported in accordance with State law for one (1) of two (2) allegations. Additionally, the facility failed to conduct a thorough investigation into this allegation, which was that a certified nursing assistant (CNA) was giving residents oral medications and an insulin injection. Facility census: 84. Findings include: a) During an interview conducted with a quality aide (QA - Employee #0) on the morning of 03/30/11, she stated she had reported to a licensed practical nurse (LPN - Employee #83) that a CNA (Employee #64) was witnessed giving oral medications and an insulin shot around the first part of February 2011. Review of the facility's reportable files for the previous three (3) months found no evidence the LPN reported this allegation as required. Review of the facility's abuse and neglect policies found the following: ""THE INDIVIDUAL WHO OBSERVES AN INCIDENT OF ABUSE OR NEGLECT MUST BE THE ONE WHO REPORTS IT. THIS MUST BE REPORTED IMMEDIATELY TO THE LOCAL DEPARTMENT OF HUMAN SERVICES, ADULT PROTECTIVE SERVICE DIVISION..."". When interviewed on the afternoon of 03/31/11, Employee #83 confirmed Employee #0 had reported this alleged abuse / neglect to her. She stated she did not report the allegation, and she could provide no evidence that a thorough investigation had been conducted.",2014-08-01
2519,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2018-05-03,880,D,1,0,I6OM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, and staff interviews, the facility failed to ensure a resident was provided needed care and services to meet their individual needs; as evident by a breech in infection control principals while providing perineal care for a resident incontinent of bowel and bladder, that had a surgical wound from a right above the knee amputation and multiple ulcers to the left foot. Perineal care refers to washing the genitals and anal area. This practice had the potential to affect more than a limited number of residents. Resident identifier: #2. Facility census: 53 Findings included: a) Resident #2 On 04/30/18 at 3:04 PM, review of records revealed resident is cognitively intact, requires extensive assistance with activities of daily living, understands and makes herself understood, is incontinent of bowel and bladder, and requires the assistance of two (2) with a mechanical lift for transfers. Pertinent [DIAGNOSES REDACTED]. [MEDICAL TREATMENT], is the most common treatment for [REDACTED]. The resident had a right below the knee (BKA) amputation on 11/30/17, with complications in healing due to medical conditions. On 02/01/18 resident was scheduled for same day surgery for [REDACTED]. The vascular surgeon and wound care specialist decided to do a more extensive procedure and Resident #2 was admitted to the hospital and a right above the knee amputation (AKA) was performed. The AKA site appears to be healing without any signs of infection or complications. The resident has multiple mixed etiology ulcers to the left foot and amputation of left 2nd toe. On 05/02/18 at 2:47 PM, observations of Nurse Aide (NA) #9 and NA #24 providing perineal care revealed the following observations. NA#9 was holding a small plastic trash bag to discard all used soiled wash cloths and other supplies used to perform perineal care for Resident #2. On two (2) separate occasions NA #9 accidentally dropped wet used soiled wash cloths on the resident's top sheet as she was attempting to discard them in the small plastic trash bag. After peri-care was completed NA #9 spread the contaminated top sheet over top of the resident. Interview with NA#9 and NA #24 revealed the two (2) NAs acknowledged there was a breech in infection control principals concerning contaminating the top sheet with two (2) wet soiled wash cloths, and after surveyor intervention a clean top sheet was placed over the resident.",2020-09-01
2520,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2019-11-14,558,D,0,1,9CAI11,"Based on observation and staff interview, the facility failed to ensure a call light was accessible and within reach for one (1) resident This was a random opportunity for discovery. Resident identifiers: #9. Facility census: 55. Findings include: a) Resident #9 On 11/11/19 at 11:21 AM, Resident #9's call light was observed to lying on the left side of the bed, in the floor, and close to the wall. The call light was located in the floor and approximately 10 inches away from the bed out of the resident's reach. On 11/11/19 at 11:24 AM, Employee # 27, Licensed Practical Nurse (LPN), was called into room by the surveyor. LPN #27 confirmed that the resident's call light was not in reach of resident and was lying in the floor, close to the the wall behind the resident's bed. LPN #27 picked up the call light and placed the call light close to the resident. On 11/14/19 at 9:05 AM, the findings for Resident #9 was discussed with the Administrator. The Adminstrator stated she believed the resident was care planned to place call light in the floor. On 11/14/19 at 10:02 AM, the Administrator noted Resident #9 had not been care planned to place call light in the floor. No additional information was provided prior to the close of the survey on 11/15/19 at 1:15 PM.",2020-09-01
2521,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2019-11-14,610,D,0,1,9CAI11,"Based on record review and staff interview, the facility failed to thoroughly investigate resident allegations of abuse and / or neglect for Resident #56. The facility failed to conduct a thorough investigation to all potential witnesses as well as all contributing factors for residents at risk for neglect. This was a random opportunity for discovery. Resident identifiers: #56. Facility census: 55. Findings included . a) Resident #56 A review of the concern log noted an allegation of neglect from Resident #56's family. The facility log noted that the allegation had been reported to the appropriate state agencies. The allegation was reported on 08/26/19. An Adult Protective Service (APS) worker arrived at the facility on 08/26/19 on a concern from Resident #56's family. The concerns listed from the APS worker were: not properly being cared for and the care is just awful; Resident #56's Gastrostomy tube (tube inserted through the abdomen that delivers nutrition directly to the stomach) was not being cleaned and cared for; Resident #56 is a diabetic and his feet are not being cared for properly; Resident #56 is in constant pain; and Resident #56 is treated like he is not even here. The facility self-reported the allegation to all proper authorities, stating the description of the incident family reports concerns regarding plan of care. Upon review of the reported incident, the facility had the following in their investigation packet: -- reporting abuse and neglect audit checklist (dated 09/05/19) -- APS letter dated 10/21/19 -- timeline and summary of investigation -- conformations of five (5) day follow-up to OHFLAC -- completed five (5) day follow-up on reported concern (dated 09/05/19) -- completed extension request (dated 08/30/19) -- conformation of extension request -- completed immediate fax reporting of allegations (dated 08/27/19) -- conformations of immediate reporting to OHFLAC, Ombudsman, APS -- completed Adult Protective Services Mandatory Reporting Form (dated 08/27/19) -- completed grievance / complaint form (dated 08/26/19) -- Treatment Administrator Record page 3 of 12 for (MONTH) 2019. This print out had the foot care for the resident. -- nursing assistant documentation for (MONTH) 2019 (24 pages) The facility did not provide any documentation of reviewing Resident #56's blood sugars, medication regimen related to diabetes, pain medication review, pain medication administration, activity participation, treatments related to Resident #56's G tube, podiatry consults, Resident #56's diagnosis, and employee statements. Also, the facility could not provide documentation that the Ombudsman and APS were advised of the five (5) day follow-up of the investigation. On 11/14/19 at 9:00 AM, the findings were discussed with the Administrator. The Administrator was asked how the facility conducted this investigation. The Administrator stated that the staff made observations regarding how Resident #56 was being cared for. The Administrator did not feel that statements from staff members regarding Resident #56's care was necessary. The Administrator stated that the facility conducted an observation of grooming. Also, staff members conducted a chart audit for Resident #56. This chart audit was related to pain and looking to see if the facility was controlling his pain. Resident #56 did require pain medication. Also, nail care was to be observed by staff members during this time period of the investigation. The Administrator stated that the investigation was conducted by observation throughout this time frame. The Administrator was asked if there was documentation of the chart audit as well as observation made during the investigation. On 11/14/19 at 9:38 AM, the Administrator provided a typed one-page print out entitled, RESIDENT NAME Observations 8/27/19-8/30/19. This document did not contain staff names, times, shift, or staff member conducting the observations. Also, no documentation was provided for the chart audit, pain audit, or nail care observations. No further information was provided prior to the close of the survey on 11/14/`19 at 1:15 PM.",2020-09-01
2522,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2019-11-14,623,E,0,1,9CAI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the Ombudsman when Residents #19 and #50 were transferred to a local hospital. This was true for two (2) of four (4) residents reviewed for hospital transfers. Resident identifiers: #19 and #50. Facility census 55. Findings include: a) Resident #19 Record review on 11/11/19 at 12:43 PM, revealed the resident was discharged to the hospital on three different dates due to respiratory issues. On 5/22/2019 at 2:14 PM, Resident #19 was transferred to (HOSPITAL NAME) for difficulty breathing and her Oxygen saturation was in the low 80's. On 7/29/2019 at 10:58 PM, Resident #19 was transferred to (HOSPITAL NAME) for increased shortness of breath, muscle cramping, and low Oxygen saturations. On 8/25/2019 at 10:23 PM, Resident #19 was transferred to (HOSPITAL NAME) for respiratory distress, febrile, and abnormal lung sounds. A review of the Ombudsman notifications list revealed Resident #19 was not on the list sent to the Ombudsman for May, July, and (MONTH) 2019. The fax conformations were dated for 11/7/2019. On 11/13/19 at 10:22 AM, during an interview with the Social Worker (SW), Employee #78, the Ombudsman lists since (MONTH) 2019 were reviewed. SW #78 did not know why Resident #19 was not included on the list. SW #78 stated that she did pull the discharge resident list from Point Click Care (PCC), the facility's electronic charting system. SW #78 could not explain why Resident #19 was not on the list, but that is the list that I sent, so if it's not there, it's not there. On 11/14/19 at 9:04 AM, the findings were discussed with the Administrator. No further information was provided to the surveyor prior to the exit of the annual survey on 11/14/19 at 1:15 PM. b) Resident #50 A review of documentation revealed there was no evidence the facility had provided the ombudsman with notification of the transfer/discharge on 10/16/19 when the resident was sent to the hospital. Nursing notes indicate the resident was sent to the hospital when she was not easily aroused, had decreased oxygen saturation and was not alert. an order for [REDACTED]. A conversation with the Social worker. Employee #78 on 11/13/19 at 8:55 a.m. confirmed the resident's name had not been included on the list of transfers that is sent to the ombudsman in a group listing at the end of the month. A printout of names for (MONTH) 1 to the 31 did not include this resident's name of those transferred. She was transferred on the16th and her name should have been on the notification with other residents.",2020-09-01
2523,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2019-11-14,677,D,0,1,9CAI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to assist a resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain a clean upper denture. This had the potential to affect a limited number of residents. This was a random observation. Resident identifer #154. Facility census: 55. Findings Included: a) Resident #154 Resident #154 was admitted on [DATE]. Resident #154's admission nursing assessment with the date of 11/07/19, revealed the resident has a full upper denture. Resident #154 has a care plan with the date of 11/08/19 related to transition plan of care. Under the interventions on the care plan the resident is identified as having an upper denture, level of consciousness is alert, the resident is able to make self understood, and able to understand others. On 11/10/19 at 3:25 PM, License Practical Nurse (LPN) #24 writes Resident #154 is able to make needs known. The note revealed the resident requires one (1) assistance with his ADL. On 11/11/2019 at 3:13 PM, The Clinical Care Supervision (CCS)#70 writes Resident #154's requires assistance with ADL with his personal hygiene needs. Observation of Resident #154 in his room on 11/12/19 at 4:00 PM. The resident asked the surveyor whether someone could clean his denture. Nurse Aide (NA)#33 walked into Resident #154's room on 11/12/19 at 4:05 PM. The resident asked this NA if she could clean his upper denture. Surveyor observed NA #33 looking for a toothbrush, toothpaste and denture cup in the resident's belongings in the room. The NA was unable to find these items to clean the resident's upper denture. The NA left the room to retrieve a new toothbrush, toothpaste and a denture cup in order to clean Resident #154's upper denture. An interview was conducted on 11/12/19 at 4:15 PM in Resident #154's room. Registered Nurse (RN)#24, and LPN #25 observed NA #33 holding Resident #154's upper denture in her hands. The nurses observed Resident #154's upper denture plate had dried balls of substance caked on the palate, trough and around the false teeth of the denture. RN #24, LPN #25 and NA #33 confirmed Resident #154's denture was unclean and needed to be cleaned. RN #24 and LPN #25 on 11/12/19 at 4:20 PM, both revealed the staff are to put oral items, like toothbrush, toothpaste and denture cups in all residents room upon admission. RN #24, LPN #25 and NA #33 looked through Resident #154's belongings in his room. The above staff members were unable to find any oral care items. RN #24 stated that the NA are to provide oral care twice a day. The Director of Nursing (DON) on 11/13/19 at 8:15 AM, said the NA who was providing care to Resident #154 had documented on Resident #154's record that she had performed oral hygiene care. She acknowledges that because the NA documented on the resident's record that she performed oral care did not provide evidence the resident's upper denture was cleaned. The DON stated that, RN #24 and LPN #25 informed her that they had observed Resident #154's dentures on 11/12/19 at 4:15 PM, and they both verified the resident's upper denture was not clean and that Resident #154's upper denture was cleaned at this time. The DON said that an in-service was conducted on 11/12/19 to educate the staff about daily oral hygiene, denture care is to be performed twice a day, and to assure denture cup, brushes and toothpaste are in each resident rooms labeled with each residents name on them.",2020-09-01
2524,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2018-12-13,550,D,0,1,8AJM11,"Based on observatio and staff interviews, the facility failed to provide dignity for a resident during her snack. A Nurse Aide (NA) stood over a resident while assisting her with her afternoon snack. Resident identifer: #35. Facility census: 60. Findings included: a) Resident #35 On 12/10/18 at 2:36 PM, observed NA #5 assisting Resident #35 to consume her afternoon snack (strawberry ice cream). NA #5 was standing up while Resident #35 was lying in her bed. NA #5 was observed bending over while assisting Resident #35 to consume her snack. NA #5 was asked whether she always stands up when she assists residents with their snack and the NA said no. NA #5 reached over and pulled a chair closer to Resident #35's bed, sit down in the chair and then proceeded to assist Resident #35 to consume her snack (strawberry ice cream). The Administrator, on 12/10/18 at 4:07 PM, was informed of a resident lying in bed and a NA standing over a resident while the NA was assisting a resident to consume her afternoon snack. The Administrator agreed this was a dignity issue and they will retrain all of their staff.",2020-09-01
2525,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2018-12-13,554,D,0,1,8AJM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure a resident was assessed for the self-administration of medications. Resident identifier: #43. Facility census: 60. Findings included: a) Resident #43 During a medication pass with Licensed Practical Nurse (LPN)#31, Resident #43 was observed to administer artificial tear solution 0.4%, one (1) drop (GTT) to both of his eyes on 12/11/18 at 4:30 PM. Resident #43 stored the Artificial Tears solution in a red box in which the resident obtained from one of his drawers in his room. Resident #43 stated that he always keeps his eye GTT medication in his red box in his room. LPN #31 confirmed that Resident #43 does not like for us to put his eye GTT in his eyes and he has always been allowed to keep his medication in his red box in his possession. Resident #43's quarterly minimum data set (MDS) with an assessment reference date of 11/22/18 was reviewed on 12/12/18 at 9:40 AM. Under section S of the MDS, Resident is capable of self-administration of medication is marked as no for Resident #43. The physician order [REDACTED]. Instill one (1) drop in both eyes four (4) times a day for dry eye syndrome was noted. Further review of Resident #43's physician orders [REDACTED]. The artificial tears was then started again on 10/19/18 with no end date. The physician's orders [REDACTED].#43 to self-administer his own artificial tear solution to both eyes four(4) times a day. A medication administration note on 09/17/18 at 12:10 PM, written by a former employee (a licensed practical nurse (LPN)#71, documented Resident has his own eye drops, he self administers. A review of Resident #43's medical record on 12/12/18 at 9:42 AM, revealed no assessment for self- administration of medication was found. The Director of Nursing (DoN) on 12/12/18 at 9:54 AM, was asked whether the staff had completed a self administration of medication assessment for Resident #43. The DoN said if her staff had completed a self- administration of medication assessment, it would be found on a form under assessments. The DoN was informed by surveyor, there was no self-administration of medication assessment for Resident #43 found in the medical record. The DoN was asked to review Resident #43's medical record for the self-administration assessment. The DoN reviewed the medical record, and stated that her staff did not complete a self administration assessment for Resident #43. The DoN confirmed that her staff should have completed an assessment because Resident #43 does self-administer his own artificial tears. The DoN also confirmed the physician's orders [REDACTED].#43 self-administers his own Artificial tears. The DoN said she will educate her staff on when to complete an self-administration assessment form. On 12/12/18 at 1:44 PM, RNAC #70 confirmed the quarterly MDS with the ARD of 11/22/18 was codded inaccurately related to Resident #43 being capable of self-administration of medication. RNAC #70 stated that the resident should have been coded as yes, capable of self-administration of medication. RNAC #70 revealed the staff have Interdisciplinary team meeting (ID) and they discuss what residents are capable of administering medication.",2020-09-01
2526,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2018-12-13,584,E,0,1,8AJM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and resident interview, the facility failed to ensure a safe clean and comfortable environment. The facility failed to ensure Resident rooms: B-1B, C-1B, C-6B, and the men and women's shower rooms were in good repair. This has the potential to affect more than a more than a limited number. Facility census: 60. Findings included: a) Resident Rooms --Room B-1B. Observation on 12/10/18 at 1:46 PM, found a crack in the wall near the bottom of Resident #15 's bed. During an observation on 12/12/13/18 09:35 AM, with the Environmental Supervisor (ES) # 34 , the ES observed the crack in the wall near the bottom of Resident #15 bed. The ES said he was not aware of the wall being cracked. --Room C-1B. Observation of room [ROOM NUMBER]/11/18 at 9:41 AM, found a rust color on the toilet paper holder in the bathroom. During observation with the ES on 12/13/18 at 9:37 AM, the ES observed the rust color on the toilet paper holder in the bathroom and said he was not aware of the rust that accumulated on the toilet paper holder. --Room C-6B. Observation of room [ROOM NUMBER]/10/18 at 04:27 PM, Resident #6 said the upper overhead light blinks constantly when the light is turned on. Observation with the ES on 12/13/18 at 9:41 AM, the maintenance man went over and twisted the bulb but it did not quit blinking. The ES said he would replace the bulb. b) Men's shower room Observations of the men's and shower room on 12/10/18 at 6:00 PM found the following issues: --Upon entrance to the men's shower room, a section of vinyl wall covering about two (2) feet long was pulled loose from the door frame. Multiple round, black-colored spots were seen on the wall beneath the loose wall covering. --The inside door handle of the men's central bath was loose-fitting and not secure. --The men's first shower stall had missing and/or broken ceramic floor tiles. A two (2) inch by two (2) inch white colored tile square was dislodged from the shower stall floor and was found setting loose on top of other floor tiles. Half of another shower stall floor tile was found setting on top of other tiles on the floor. Because it was broken in half, it was triangular shaped and jagged. The other half was missing. Another two (2) inch by two (2) inch square tile on the shower room floor was missing with no sign of its location. --The men's first shower stall floor was grossly discolored and in need of cleaning and/or new grout. A black-colored, mold-like substance was present on the left side of the stall where the floor tile met the tiled wall. The right side of the stall where the floor tile met the tiled wall contained dirty-looking gray-colored grout. The grout between the tiles on the floor was discolored, dingy, and dirty looking. --Brown/rust-colored stains were present on the left side of the same shower stall wall beneath and to the left of two (2) metal fixtures on the wall. The purpose of the two (2) metal fixtures is unknown. --A ceramic wall tile about fifteen (15) inches from the floor was missing in the men's second shower stall. The ceramic material immediately above the missing tile was jagged and sharp. This posed a potential to cut if a lower extremity were to brush up against it. --On the floor outside the showers and toward the back wall, a pink hair brush with a lot of hair in it lay on the floor. A spray bottle of fragrance lay on the floor. Three (3) potty chair lids lay on the floor. Five (5) white towels and five (5) five white wash cloths were stacked on top of a shower chair. --In the handicapped bathroom beside the men's shower area sat a shower chair between the toilet and the sink. On top of this shower chair sat the inside or pot portion of a commode chair. It looked dry, but contained numerous spots of light brown colored material which needed cleaned. An interview was conducted with the director of nursing (DON) on 12/10/18 at 6:05 PM. She said staff is not supposed to store towels and washcloths on the shower chair, and personal grooming items and potty chair lids are not supposed to lay on the floor. She agreed the potty chair was not cleaned and stored properly. She referred to the environmental supervisor for the other issues. On 12/10/18 at 6:08 PM an interview was conducted with the environmental supervisor #34. He said the shower rooms are cleaned daily at 7:00 AM before the day's showers begin. He said the shower rooms are cleaned again at lunchtime while the residents eat their noonday meals. He acknowledged the environmental issues listed above. He said that he would repair the jagged wall tile in the second shower stall immediately, and remove the floor tiles which are loose and out of place in the first shower stall immediately. He said he will have to schedule a whole day to deep clean and re-grout and replace missing ceramic tiles in the first shower stall floor as it will take about twenty-four (24) hours to dry. He said he would tighten up the loose door handle and secure the loose vinyl wall covering right away. He said he was not made aware of these issues until today.",2020-09-01
2527,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2018-12-13,641,D,0,1,8AJM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure a quarterly minimum data sets (MDS) was accurately coded to reflect whether a resident is capable of self- administering medication. This was true for one (1) of 20 residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: #43. Facility census 60. Findings included: a) Resident #43 During a medication pass with Licensed Practical Nurse (LPN)#31, Resident #43 was observed to administer artificial tear solution 0.4% one (1) drop (GTT)to both of his eyes on 12/11/18 at 4:30 PM. Resident #43 stored the Artificial Tears solution in a red box in which the resident obtained from one of his drawers in his room. Resident #43 stated that he always keeps his eye GTT medication in his red box in his room. LPN #31 confirmed that Resident #43 doesn't like for us to put his eye GTT in his eyes and he has always been allowed to keep his medication in his red box in his possession. Resident #43's quarterly minimum data set (MDS)with an assessment reference date of 11/22/18 was reviewed on on 12/12/18 at 9:40 AM. Under section S of the MDS, Resident is capable of self-administration of medication is marked as no for Resident #43. The physician order [REDACTED]. Instill one (1) drop in both eyes four (4) times a day for dry eye syndrome was noted. Further review of Resident #43's physician orders [REDACTED]. The artificial tears was then started again on 10/19/18 with no end date. The physician's orders [REDACTED].#43 to self-administer his own artificial tear solution to both eyes four(4) times a day. A medication administration note with the date of 09/17/18 at 12:10 PM, from an former employee (a licensed practical nurse (LPN)#71, wrote in her note Resident has his own eye drops, he self administers. A review of Resident #43's medical record on 12/12/18 at 9:42 AM, revealed no assessment for self- administration of medication was found. The Director of Nursing (DoN) on 12/12/18 at 9:54 AM, was asked whether the staff had completed a self administration of medication assessment for Resident #43. The DoN said if her staff had completed a self- administration of medication assessment, it would be found on a form under assessments. The DoN was informed by surveyor, there was no self-administration of medication assessment for Resident #43 found in the medical record. The DoN was asked to review Resident #43's medical record for the self-administration assessment. The DoN reviewed the medical record, and stated that her staff did not complete a self administration assessment for Resident #43. The DoN confirmed that her staff should have completed an assessment because Resident #43 does self-administer his own artificial tears. The DoN also confirmed the physician's orders [REDACTED].#43 self-administers his own Artificial tears. The DoN said she will educate her staff on when to complete an self-administration assessment form. On 12/12/18 at 1:21 PM, the DoN was asked to review the quarterly MDS with an ARD of 11/22/18. The DoN was asked whether the Registered Nurse Assessment Coordinator (RNAC)coded accurately related to Resident #43 capable of self-administration of medication. The DoN confirmed the RNAC did not accurately code Resident #43 quarterly MDS with the ARD of 11/22/18. Resident #43 should have been coded as Yes. On 12/12/18 at 1:44 PM, RNAC #70 Shannon confirmed the quarterly MDS with the ARD of 11/22/18 was codded inaccurately related to Resident #43 being capable of self-administration of medication. RNAC #70 stated that the resident should have been coded as yes, capable of self-administration of medication. RNAC #70 revealed the staff have ID ( Interdisciplinary team meeting) and they discuss what residents are capable of administering medication.",2020-09-01
2528,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2018-12-13,656,D,0,1,8AJM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to implement the care plan for one (1) of twenty (20) sampled residents. Resident #38's care plan was not implemented as it pertained to hygiene. Resident identifier: #38. Facility census: 60. Findings included: a) Resident #38 Observation on 12/10/18 at 6:30 PM found this resident sitting in the main dining room. A nursing assistant sat beside her and fed the evening meal to her. Three (3) fingers on each hand had dirt beneath the nails. At 11:30 AM on 12/11/18 she was observed again with dirt beneath the nails of three (3) fingers on each hand. The medical record was reviewed on 12/12/18. The most recent minimum data set (MDS) with assessment reference date (ARD) 11/15/18, assessed her cognitive functioning as severely impaired. [DIAGNOSES REDACTED]. Review of the care plan found a focus on the resident's self care performance deficit related to dementia and limited mobility. Interventions included that she required extensive assistance of one (1) person for personal hygiene. The care plan directed to Check nail length and trim and clean weekly and as necessary. Observation on 12/12/18 at 2:50 PM found the fingernails visible on her left hand as she lay in her bed. Dirt was present beneath the fingernails of the ring finger, index finger, and middle finger of the left hand. An interview was conducted on 12/12/18 at 2:55 PM with nursing assistant #62 (NA#62). She said she showered this resident yesterday. She said they always clean fingernails during showers, plus they clean fingernails in between shower days if they are found dirty. At 3:00 PM on 12/12/18 the director of nursing (DON) assessed the condition of the resident's fingernails as the resident reclined in her bed. She agreed that the fingernails of the ring finger, index finger, and middle finger of the left hand were dirty and needed cleaned. She then uncovered the resident's right hand from beneath the covers. She agreed that the fingernails of the pinky finger, ring finger, and the middle finger of the right hand were dirty and needed cleaned. She whispered that sometimes this resident sometimes plays in things. The DON was informed that this was the third observation of dirty fingernails on three (3) consecutive days. On 12/12/18 at 4:00 PM the minimum data set nurse and the DON provided a copy of the resident's care plan. The DON acknowledged that the care planned intervention to clean the fingernails as necessary was not followed.",2020-09-01
2529,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2018-12-13,677,D,0,1,8AJM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and medical record review, the facility failed to ensure adequate fingernail hygiene was provided to a dependent resident. This was evident for one (1) of three (3) residents reviewed for activities of daily living. Resident identifier: #38. Facility census: 60. Findings included: a) Resident #38 Observation on 12/10/18 at 6:30 PM found this resident sitting in the main dining room. A nursing assistant sat beside her and fed the evening meal to her. Three (3) fingers on each hand had dirt beneath the nails. At 11:30 AM on 12/11/18 she was observed again with dirt beneath the nails of three (3) fingers on each hand. The medical record was reviewed on 12/12/18. The most recent minimum data set (MDS) with assessment reference date (ARD) 11/15/18, assessed her cognitive functioning as severely impaired. [DIAGNOSES REDACTED]. Review of the shower schedules found she was scheduled for showers every Tuesday and Thursday. Observation on 12/12/18 at 2:50 PM found the fingernails visible on her left hand as she lay in her bed. Dirt was present beneath the fingernails of the ring finger, index finger, and middle finger of the left hand. An interview was conducted on 12/12/18 at 2:55 PM with nursing assistant #62 (NA#62). She said she showered this resident yesterday. She said they always clean fingernails during showers, plus they clean fingernails in between shower days if they are found dirty. At 3:00 PM on 12/12/18 the director of nursing (DON) assessed the condition of the resident's fingernails as the resident reclined in her bed. She agreed that the fingernails of the ring finger, index finger, and middle finger of the left hand were dirty and needed cleaned. She then uncovered the resident's right hand from beneath the covers. She agreed that the fingernails of the pinky finger, ring finger, and the middle finger of the right hand were dirty and needed cleaned. She whispered that sometimes this resident sometimes plays in things. The DON was informed that this was the third observation of dirty fingernails on three (3) consecutive days A brief interview was conducted with NA #62 at 3:05 PM on 12/12/18. Upon inquiry, she said she showered this resident yesterday after breakfast around 9:30 AM. She said she cleaned the resident's fingernails during the shower, and that she was unaware the fingernails were dirty again. She said the resident may have put her fingers in her food at lunchtime today. Another interview was conducted with the DON on 12/12/18 at 4:00 PM. No further information was provided at this time.",2020-09-01
2530,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2018-12-13,689,E,0,1,8AJM11,"Based on observation, staff interview and record review the facility failed to ensure the environment over which it had control was as free from accident hazards as possible. There was a key to the janitor's closet on the C - Hall hanging from a spring like cord by the door which made it easily accessible to residents. This practice has the potential to effect more than an isolated number of residents. Facility census: 60. Findings Include: a) Observations of the C hall janitors closet at 4:30 p.m. on 12/12/18 with the Nursing Home Administrator ( NHA), Director Of Nursing (DON), and the Maintenance Director found a key hanging by the door on a pink spring like cord. This key was to the janitors closet and was easily pulled down and used to open the door by the surveyor. Inside the janitors closet the following chemicals were found: -- Quat Disinfect Cleaner Ready to use. A Review of Material Safety Data Sheet (MSDS) found the following Potential Health Effects: Eye Contact: Signs/Symptoms may include Mild eye irritation may include redness, pain and tearing. Skin Contact: Mild Skin Irritation: Signs/Symptoms may include localized redness, swelling, and itching. Inhalation: Respiratory Tract Irritation: Signs/Symptoms may include cough, sneezing, nasal discharge, headache, hoarseness, and nose and throat pain. Ingestion: Gastrointestinal Irritation: Signs/Symptoms may include abdominal pain, stomach upset, nausea, vomiting and diarrhea. -- Glass Cleaner Ready To use. A review of MSDS sheet found the following Potential Health Effects: Eye Contact: Signs/Symptoms include Mild eye irritation may include redness, pain and tearing. Skin Contact: Mild Skin Irritation: Signs/Symptoms may include localized redness, swelling, and itching. Inhalation: Respiratory Tract Irritation: Signs/Symptoms may include cough, sneezing, nasal discharge, headache, hoarseness, and nose and throat pain. Ingestion: Gastrointestinal Irritation: Signs/Symptoms may include abdominal pain, stomach upset, nausea, vomiting and diarrhea. -- Neutral Cleaner Ready To Use. A review of MSDS sheet found the following Potential Health Effects: Eye Contact: Signs/Symptoms may include Mild eye irritation may include redness, pain and tearing. Skin Contact: No health effects are expected. Inhalation: Respiratory Tract Irritation: Signs/Symptoms may include cough, sneezing, nasal discharge, headache, hoarseness, and nose and throat pain. Ingestion: Gastrointestinal Irritation: Signs/Symptoms may include abdominal pain, stomach upset, nausea, vomiting and diarrhea. -- Bathroom Disinfectant Cleaner. A review of MSDS sheet found the following Potential Health Effects: Eye Contact: Signs/Symptoms include Mild eye irritation may include redness, pain and tearing. Skin Contact: Mild Skin Irritation: Signs/Symptoms may include localized redness, swelling, and itching. Inhalation: Respiratory Tract Irritation: Signs/Symptoms may include cough, sneezing, nasal discharge, headache, hoarseness, and nose and throat pain. Ingestion: Gastrointestinal Irritation: Signs/Symptoms may include abdominal pain, stomach upset, nausea, vomiting and diarrhea. -- Comet Cleaner with Bleach Ready to Use. A review of the MSDS sheet found the following Hazards Identification. Eyes: Health injuries are not known or expected under normal use. Accidental exposure will cause a moderate but transient irritation. Skin: Health Injuries are not known or expected under normal use. (MONTH) cause transient irrigation. Prolonged or repeated contact may be drying to the skin. Inhalation: Health injuries are not known or expected under normal use. Irritating to mucous membranes. Ingestion: Health injuries are not known or expected under normal use. Ingestion may cause gastrointestinal irritation, nausea, vomiting, and diarrhea. -- Bright Solutions Fireball. Hazards Statements: Causes Skin irritation. Causes serious eye irritation. The Maintenance Director removed the key and stated they would figure something else out. He stated that no residents had ever tried to go into the janitors closet but they would remove it.",2020-09-01
2531,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2018-12-13,761,E,0,1,8AJM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and policy review, the facility failed to ensure medications were labeled and dated once they were opened. This had the potential to effect more than a limited number of residents. Facility census 60. Findings included: a) Medication storage room. Observation on 12/10/18 at 5:30 PM, with licensed practical nurse (LPN) #63 found two (2) multi-vial of [MEDICATION NAME] purified protein derivative (PPD) in the medication storage room refrigerator unlabeled and undated. LPN #63 confirmed their policy is to label, date the day they initially break the vial, and place a new expiration on the PPD vial. The Director of Nursing (DoN) on 12/10/18 at 5:50 PM, confirmed the staff should have placed a date the medication was opened and an new expiration on the vial once the vial was opened. A review of the facility's medication storage policy on 12/12/18 at 11:00 AM, showed when the original seal of a manufacturer's container or vial is initially broken, the nurse shall label the medication with the date opened and the new date of expiration.",2020-09-01
2532,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2018-12-13,842,E,0,1,8AJM11,"Based on record review and staff interview, the facility failed to ensure Resident #48, #57, and #59's medical records were complete and accurate. For Resident #59 the facility failed to ensure the discharge summary was kept in the residents medical record. The facility failed to ensure that Resident #48's showers were documented in his medical record. For Resident #57 the facility failed to ensure that her blood sugar was documented accuratly in the residents record. This was true for three (3) of 20 records reviewed during the Long Term Care Survey Process. Resident identifiers: #48, #57, and #59. Facility Census: 60. Findings included: a) Resident #48 A review of Resident #48's medical record on 12/12/18 at 4:30 p.m. found no documentation indicating Resident #48 had received a shower while at the facility. An interview with the Director of Nursing (DON) at 9:42 a.m. on 12/13/18 confirmed Resident #48's showers were not documented in the resident record. She indicated the residents task button for showers was not turned on. She provided documenting kept in a notebook by the shower aides which showed Resident #48 received a shower on 11/26/18, 11/30/18, and 12/07/18. She agreed these showers were not documented on Resident #48's medical record. b) Resident #57 A review of Resident #57's medical record at 9:42 a.m. on 12/12/18 found on 10/25/18 Resident #57's blood sugar was documented at 38. An interview with the Director of Nursing (DON) at 11:26 a.m. on 12/1/2/18 found the nurse who obtained the blood sugar was working on this date. She indicated she had spoken with him and he felt he had reversed the numbers when putting it into the residents record. She stated, He said he would have remembered that and would have done something about it. An interview with Licensed Practical Nurse (LPN) #18 at 11:39 a.m. on 12/12/18. When asked about Resident # 57's blood sugar of 38 on 10/25/18. He stated, That has to be a mistake. I have never had a resident with a blood sugar of 38. I would remember that and would have done something. He stated, I must have entered the numbers in reverse order or something, but her blood sugar was not 38. c) Resident #59. A review of Resident #59's medical record on 12/12/18 at 3:45 PM, revealed that Resident #59's discharge summary was not in the medical record. Social worker (SW) #24 and the director of nursing (DoN) on 12/12/18 at 3:49 PM, was asked why Resident #59's discharge summary report was not in her medical record. The DoN stated they will have to look for the discharge summary report. On 12/12/18 at 3:56 PM, the SW #24 said the physician is sending the discharge summary to them. She was asked why the discharge was not on Resident #59 medical record and the SW said she could not answer this question. The SW stated that she would get the DoN to answer this question. The Don on 12/12/18 at 4:03 PM, confirmed she could not find Resident #59's discharge summary report in the medical record. The DoN then handed a copy of Resident #59's discharge summary report. The DoN stated that she had to call the physician and ask for Resident #59's discharge summary report. The physician just faxed the facility a copy so the discharge summary will be in placed in Resident #59'S medical record. The DoN stated the discharge summary report was not put in the chart in a timely manner.",2020-09-01
2533,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2018-12-13,880,D,0,1,8AJM11,"Based on staff interview and facility's guidelines's on cleaning and disinfecting the glucometers, the facility failed to provide a safe and sanitary to help prevent the development and transmission of communicable diseases and infections. The staff was not properly cleaning and disinfecting the glucometers. This had the potential to affect more than a limited number of resident residing in the facility who would have their blood sugar (glucose)checks. Facility census 60. Findings included: a)Glucometer not being cleansed and disinfected properly. During a review of the medication cart for medication storage and labeling on 12/10/18 at 5:30 PM, licensed practical nurse (LPN)#63 opened her medication cart, and on the top drawer was a glucometer (a diagnostic instrument for measuring blood glucose ). LPN #63 verified the glucometer checks multiple residents blood glucose level in the facility. LPN #63 was asked what do you clean and disinfect your glucometer. LPN #63 said I clean (pointing her finger to the alchol pad in the drawer) the meter with these alchol pads. There were no other forms of cleaning and disinfecting products found on the medication cart during the medication storage and labeling review. The Director of Nursing (DoN) was asked on 12/ 10/18 at 6:03 PM whether the facility educate the nursing staff to use alcohol to clean and disinfect their glucometers. The DoN stated, no, we use bleach germicidal wipes to clean the glucometers. The DoN inquired on whether her staff had told me they used alcohol pads and I informed the DoN a nursing staff had verified they use alcohol pads. She confirmed the nursing staff does not use alcohol pads. The DoN, United Charge Nurse (UCN)#7 and surveyor on 12/12/18 at 11:30 AM, went onto the B hallway where LPN # 31 was standing by her medication cart. LPN #31 was asked once surveyor was at the medication cart and facing LPN #31, how do you cleaning and disinfect your glucometer. LPN #31 opened her cart drawers and pulled out PDI sani-hands out of her cart. The LPN said she uses PDI sani-hands to clean her glucometer. The DoN and UCN #7 was present when LPN #31 was asked what did she use to clean and disinfect her glucometer and they both disagreed with LPN #31, and stated that, This is not what we use. The DoN and UCN both agreed that the have single packs to clean the glucometer and/or Clorox bleach germicidal wipes for healthcare. The DoN provided a container of the Clorox bleach germicidal wipes for healthcare to the medication cart, the staff however did not show any single pack of germicidal wipes. A review of the manufacture's instruction in which this is the disinfecting guidelines the facility's follows, finds to disinfect your monitor with using a solution of 10% bleach (one part bleach to ten parts water), Alternatively, and EPA -registered disinfectant detergent or germicide that is approved for healthcare settings may be used.",2020-09-01
5257,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2015-09-30,278,B,0,1,C8H511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure each individual completing Minimum Data Set (MDS) assessments completed the assessments to accurately reflect the resident's condition. Resident #83's assessment did not identify weight loss. Resident #9's MDS did not indicate the resident received Hospice services. Resident #34's assessment did not include the resident's active [DIAGNOSES REDACTED].#62's assessment did not identify the use of antianxiety medication. Assessment coding errors were found for four (4) of sixteen (16) sample residents. Resident identifiers: #83, #9, #34, and #62. Facility Census: 58. Findings include: a) Resident #83 This resident's 14-day MDS assessment, with an assessment reference date (ARD) of 06/26/15, listed the resident's weight as 165 pounds (#). The next MDS, with an ARD of 07/21/15, indicated the resident's weight was 139#, but was not identified as a weight decline of 5% or more in the last month in item K0300. On 09/30/15 at 10:30 a.m., the MDS coordinator verified the 07/21/15 assessment should have been coded showing the weight loss. b) Resident #9 Review of the resident's quarterly MDS with an ARD of 07/30/15, found the assessment failed to show the resident was receiving hospice services during the look back period for the assessment. A significant change MDS with an ARD of 05/16/15, had identified the resident received Hospice services. Hospice services had begun at that time and were identified on the MDS. It was not carried over onto the 07/30/15 assessment. Discussion with the MDS coordinator on 09/29/15 at 10:25 a.m. revealed the assessment was coded in error and should have indicated the resident continued to receive hospice services. c) Resident #34 A review of the medical record for Resident #34, on 09/29/15 1:35 p.m., revealed the quarterly MDS assessment with an assessment reference date (ARD) of 08/20/15, did not accurately reflect a [DIAGNOSES REDACTED]. The current physician's orders [REDACTED].#34 had a current order for [MEDICATION NAME] 200 milligrams (mg) at bedtime for [MEDICAL CONDITION] disorder. Review of the Medication Administration Record [REDACTED]. An interview on 09/29/15 at 2:35 p.m., with the MDS Coordinator, verified Section I Active [DIAGNOSES REDACTED].#34. d) Resident #62 Review of medical records found a quarterly minimum data set (MDS), with an assessment reference date (ARD) of 09/18/15, identified the resident received an antipsychotic, a diuretic, an anticoagulant, and antibiotic on each of the 7 days in the look back period in Section N, Item N0410 - Medication Received. On 09/29/15 at 10:55 a.m., review of the resident's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of physician orders [REDACTED]. On 09/30/15 at 9:46 a.m., the DON verified the antianxiety medication should have been indicated on the MDS with an ARD of 09/18/15 for the [MEDICATION NAME] Resident #62 was taking for anxiety.",2019-02-01
5258,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2015-09-30,334,D,0,1,C8H511,"Based on record review, policy review, and staff interview, the facility failed to develop and implement policies and procedures which ensured all residents were educated on the risks of refusing influenza and/or pneumococcal immunization vaccines. The facility also failed to ensure the reason for not receiving the influenza and/or pneumococcal immunization vaccine, whether due to contraindication or refusal, was documented in each resident's medical record. The facility failed to ensure Resident #51 was offered the influenza and/or pneumococcal immunization vaccine. This practice affected one (1) of five (5) residents reviewed for vaccinations. Resident identifier: #51. Facility census: 58. Findings include: a) Resident #51 Review of Resident #51's medical record revealed the record did not include any documentation that indicated the resident did or did not receive the influenza immunization from the facility due to any medical contraindications or resident/legal representative refusal. No evidence was found in the resident's medical record to indicate the facility provided the resident, or resident's legal representative, any education regarding the benefits and potential side effects of influenza and/or pneumococcal immunization. Review of the facility's policies for influenza and pneumococcal immunizations revealed the facility's policies did specify, Upon admission to the facility, permission will be obtained from the resident or the resident's legal representative for the pneumococcal vaccine given as indicated by current acceptable standards of immunization . Upon admission to the facility, explain to the resident and/or the resident's legal representative that the influenza vaccine is administered annually and consent will be obtained each year. Also in the policy under 'Influenza Vaccine,' #2 stated, Review the influenza immunization informed consent with the resident and/or responsible party annually Review of the facility's policies for influenza and pneumococcal immunizations revealed the facility's policies did not specify educating resident/legal representative on the risk of refusing the vaccines. Nor did the policy indicate the resident had the right to refuse the immunizations, or that the refusal must be documented, at a minimum with the following information: - That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of influenza immunization; and - That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. On 09/29/15 at 12:05 p.m., interview with the Director of Nursing (DON), revealed an influenza or pneumococcal vaccination consent form could not be found for Resident #51 for the 2014 - (YEAR) seasons. The DON stated prior to resident's admission to the facility, the vaccines had been offered at the local hospital and were refused by her MPOA (Medical Power of Attorney). The DON said they were contacting the local hospital that Resident #51 had been transferred from, and asking them to fax a copy where it had been offered and refused. At 11:15 a.m. on 09/30/15, the DON provided a copy of a fax from the hospital dated 11/18/14 that indicated the immunizations had been refused. At that time the DON confirmed the facility could not provide any evidence the facility did, or did not, offer or provide an influenza or pneumococcal immunization for Resident #51. The facility could not provide any evidence the facility offered or provided Resident #51 or Resident #51's legal representative the required education regarding the benefits and risks of refusing the influenza and/or pneumococcal vaccines.",2019-02-01
5259,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2015-09-30,371,B,0,1,C8H511,"Based on staff interview and observation, the facility did not ensure food was stored in a sanitary manner. Food items in the dry food storage area and the walk-in refrigerator were found to not be labeled with the name of the item or the date it was opened. This practice had the potential to affect more than a limited number of residents as all residents were fed from this central location. Facility census: 58. Findings include: a) During the initial tour of the dietary department at 11:15 a.m. on 09/27/15, the following items were observed: 1. In the dry food storage area a package of elbow macaroni was on the shelf not labeled or dated of when it was opened. 2. The walk-in refrigerator had a plastic bag that contained lettuce which was not dated of when it was opened. 3. The walk-in freezer storage area had a plastic bag which had broccoli and cauliflower in it and the package did not contain a date of when the product was opened. This practice did not allow the dietary staff to determine how long the product has been opened and if it was still safe for consumption. b) These items were brought to the attention of the cook at the time and then was discussed with the administrator and consultant dietitian on 09/29/15 prior to lunch.",2019-02-01
5260,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2015-09-30,431,E,0,1,C8H511,"Based on observation, staff interview, policy review, and review of the manufacturer's drug insert, the facility, in coordination with the licensed pharmacist, failed to ensure safe handling, including disposition, of all medications. They failed to label multi-dose vials of medications when opened to ensure safe administration of all medications. This was found for two (2) of four (4) purified protein derivative multi-dose vials stored in the medication room refrigerator. The vials were not dated when opened, ensuring safe administration. This practice had the potential to affect more than a limited number of residents. Facility census: 58. Findings include: a) Observation of the medication room refrigerator, on 09/27/15 at 12:30 p.m., with Licensed Practical Nurse (LPN) #22, revealed two (2) opened multi-dose vials of purified protein derivative solution, stored in a plastic bag with two (2) unopened vials. The bag contained a label which was dated 07/13/15 and indicated only three (3) vials had been dispensed. LPN #22 checked the vials to determine when they were opened, and related neither the bottle, nor the box was dated. Upon inquiry, the nurse related the vials should have been dated when opened, and believed the vials should be discarded after thirty (30) days. The LPN confirmed she could not verify when the medication was opened. On 09/29/2015 at 9:25 a.m., an interview with the director of nursing (DON) revealed multi-dose vials were to be dated when opened and destroyed 30 days after opening. She related she had made rounds yesterday (09/28/15), found unlabeled PPD vials, and disposed of them. Review of the medication storage policy, on 09/29/15 at 4:00 p.m., revealed multi-dose vials should be discarded according to when the manufacturer's stated expiration date was reached, or if not specifically noted in the manufacturer's package insert should not exceed 28 days once the vial had been opened. The manufacturer's insert for PPD solution, reviewed on 09/29/15 at 4:00 p.m., revealed, Vials in use more than 30 (thirty) days should be discarded due to possible oxidation and degradation which may affect potency.",2019-02-01
5261,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2015-09-30,514,D,0,1,C8H511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility did not maintain accurately documented clinical records on each resident in accordance with accepted professional standards and practices. Two (2) different physician's orders [REDACTED]. Resident identifier: #32. Facility census: 58. Findings include: a) Resident #32 A Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. An interview with the Director of Nursing (DON), on 09/28/15 at 8:30 a.m., revealed the orders required clarification. She related she believed the resident received two (2) doses at 9:00 p.m., but would ask for clarification. During a follow-up interview at 9:38 a.m. with the DON, she indicated the order had been clarified, and should have been [MEDICATION NAME] 2 mg PO at 9:00 p.m. However, an interview with Registered Nurse #57, on 09/30/15 at 9:09 a.m., confirmed the order dated 09/14/15 to increase [MEDICATION NAME] 0.5 mg PO to 1 mg PO was transcribed incorrectly, resulting in a medication error related to time of administration. The nurse related the increased dose should have been scheduled for 9:00 a.m. A review of the Medication Administration Record [REDACTED]. Additionally psychiatry visit summaries revealed a visit on 09/03/15 which recommended to increase [MEDICATION NAME] 1 mg po bid for behaviors; and a physician's contact note dated 09/14/15 at 14:58 (2:58 p.m.) indicated the recommendation was to increase [MEDICATION NAME] 0.5 mg to 1 mg, and the MD (medical doctor) agreed with order recommendations. Another note, dated 09/11/14 again indicated to Increase [MEDICATION NAME] to 1mg po (by mouth) bid for behaviors related to disease process per recommendations by (psychiatrist group.) An informed consent, dated 09/14/15, indicated Resident #32 should have received [MEDICATION NAME] 1 mg po (by mouth) twice (bid) daily. A family/MPOA (medical power of attorney)/responsible party contact note, dated 09/14/15 t 15:02 (3:02 p.m.) also noted the recommendation to increase [MEDICATION NAME] from 0.5 mg to 1mg. Further review of the medical record, at 9:00 a.m., revealed a progress note, dated 09/14/15 at 14:58 (2:58 p.m.) which indicated the resident was seen by psychiatry due to behaviors (screaming yelling hitting) and indicated a recommendation to increase [MEDICATION NAME] from 0.5 mg to 1 mg. The note also indicated the physician agreed with the recommendation. Another progress note at 15:02 (3:02 p.m.) also noted the MD (medical doctor) recommended to increase [MEDICATION NAME] from 0.5 mg to 1 mg daily physician's orders [REDACTED].#32 received [MEDICATION NAME] 0.5 mg PO in the morning and 1 mg PO in the evening, prior to 09/14/15. An order on 09/14/15 indicated [MEDICATION NAME] 0.5 mg PO in the morning was discontinued, and a new order written for [MEDICATION NAME] 1 mg PO daily, which was scheduled for administration at 9:00 p.m. Resident #32 had two (2) orders for [MEDICATION NAME]. The orders were for 0.5 mg in the a.m. and 1 mg in the p.m. The a.m. order was changed to 1 mg. The 1 mg [MEDICATION NAME] should have been administered twice daily at 9:00 a.m. and at 9:00 p.m. Instead, the facility transcribed the morning dose to be given at 9:00 p.m. Both doses ended up scheduled for 9:00 p.m. This created a medication time error. b) Gradual Dose Reduction (GDR) Additionally, a review of the consultant pharmacist's communication to the physician form, dated (MONTH) (YEAR), indicated a recommendation for a gradual dose reduction (GDR) for [MEDICATION NAME]. A handwritten order on the communication form, dated 08/25/15, noted to decrease [MEDICATION NAME] to 0.25 mg po in the morning and 1 mg po in the evening. Physician's telephone orders, electronic medical record orders, and all progress notes, consults, physician's visits, reviewed on 09/29/15 at 4:30 p.m., revealed no evidence the GDR order was implemented. Registered Nurse (RN) #57 also reviewed progress notes, physician's orders [REDACTED]. RN #57 confirmed the order for the gradual dose reduction; dated 08/25/15 was not transcribed. The failure to transcribe resulted in a medication error due to incorrect dosage. On 09/30/15 at 9:20 a.m., the director of nursing also confirmed the orders were transcribed incorrectly.",2019-02-01
5900,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2015-07-02,225,D,1,0,DYHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the reportable abuse/neglect allegations, staff interview, and abuse/neglect policy review, the facility failed to ensure it thoroughly investigated one (1) of the three (3) allegations of abuse/neglect reviewed during a complaint investigation. Resident #37 alleged the facility did not provide incontinence care timely and did not remove a lift pad from underneath him after he was transferred. Resident identifier: #37. Facility census: 54. Findings include: a) Resident #37 On 07/02/15 at 10:20 a.m., a review of the facility's reportable abuse/neglect allegations revealed the facility completed an investigation into an allegation of neglect involving Resident #37. The allegation was made on 05/02/15 and the facility completed the investigation on 05/07/15. The immediate reporting of the allegation by the facility to the Nurse Aide Program stated Resident #37 did not receive care in a timely manner. A review of the investigation revealed the facility collected statements from fifteen (15) direct care staff members. - Nurse Aide (NA) #7 provided a statement dated 05/06/15, which said, At approximately 8 am (8:00 a.m.) (Name of Resident #37) yelled out for assistance. CNA (certified nurse aide) (name of nurse aide) and I went into room. We found him soiled and with a lift pad beneath him, we cleaned him up and removed the lift pad. Later during the day around 2 (2:00 p.m.) during rounds we went into his room. He was wet and soiled but stated he wasn't and did not need assistance. We asked to change him. At first he said 'no' 'I'm fine' and then allowed us to change him once we checked and explained how to him how soiled he was. There was no indication on the statement as to what date NA #7 referred to in this statement. There was also no indication the facility had taken a statement from the other nurse aide who was mentioned in this statement as assisting NA #7 in providing care to Resident #37. - A statement from Licensed Practical Nurse (LPN) #51, dated 05/02/15, stated, (typed as written) Approximately 0800 am (8:00 a.m.) two CNA's (nurse aides) came to report to me that (name of Resident #37) stated that he had not been changed all night when I approached resident he still had a lift pad underneath him. Me and co-nurse assessed resident for reddened areas and break down. Residents skin was free of breakdown. Resident had minimal redness to bilateral inner gluteal folds with no open areas. [MEDICATION NAME] was applied to reddened area. - The facility identified Nurse Aide (NA) #14 as the alleged perpetrator. However, in the statement provided, NA #14 did not address whether or not she used a lift pad with the resident or whether she provided incontinence care during her shift of work. - SW #10 obtained a statement from the alleged victim (Resident #37) on 05/04/15. The statement said, This social worker met with (name of Resident #37) on 5/4/15 to discuss care and services. (Resident #37) states he was very satisfied with his care. I asked if he was given care as often as he felt he needed it and he said he 'always gets good care.' He said there was only one incident that had occurred over the weekend. When I asked him to tell me about it he said that over the last weekend (5/1-5/3) on one night the nurse had left a lift pad under him after providing care. I asked him if he had requested that someone else remove it. He said 'Honey I forgot to even mention it when they came back in' The facility collected statements from fifteen (15) direct care staff members. Ten (10) staff members wrote in their statements that they were in the resident's room, but did not address the issue of whether or not they saw a lift pad under the resident, or if they noticed if the resident had been incontinent. During an interview with Social Worker (SW) #10, on 07/02/15 at 12:00 p.m., she reviewed the allegation and the statements the facility collected. She confirmed she had not asked all direct care staff that were interviewed about whether or not they had used a lift pad on the resident or noticed a lift pad under the resident. The statements also did not reflect if they noticed, or did not notice, the resident to be incontinent when they had been in his room. A review of the statements taken from the fifteen (15) staff who provided statements revealed the staff did not always clarify the date/time they were referring to when they wrote their statements. The SW commented that she had not noticed that. The SW further stated that when investigating the issue of incontinence care, she had not checked the documentation completed by all nurse aides who worked on the date the allegation occurred to determine how many different times incontinence care was provided and who provided the care to the resident on 05/02/15. The five-day follow -up form completed by the facility stated, Unsubstantiated. Investigation showed that care was provided to this resident in a timely manner. A review of the facility's policy for abuse/neglect, dated 03/01/14, revealed on page 4 of 10 included, a. The Executive Director or his/her designee will complete a chronological narrative of the investigation describing the allegation, the investigation and the conclusion based on the facts of the situation. The conclusion should state the reasons the determination was made, whether or not the allegation was substantiated or unsubstantiated, any external reporting that was completed in conjunction with the investigation, any employee education that occurred as a result of the investigation, any system changes that were made due to the investigation. The narrative should become part of the internal investigative file and be signed and dated by the investigation. The facility did not have a chronological narrative for this investigation. The chronological narrative would have given the reasons why the facility determined the allegation was unsubstantiated.",2018-07-01
5901,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2015-07-02,441,E,1,0,DYHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of personnel records, staff interview, and review of the facility's infection-control policy, the facility failed to maintain an effective infection-control program designed to provide a safe, sanitary, and comfortable environment, to help prevent the development and transmission of disease and infection. Prior to entering an isolation room, a staff member failed to put on the personal protective equipment (PPE) identified on the sign posted on the door. Additionally, the facility did not implement its policy to track and trend all residents' infections. This had the potential to affect more than a limited number of residents. Resident identifiers: #41, #23, and #55. Facility census: 54. Findings include: a) Resident #41 Observations on 07/01/15 at 10:40 a.m., found an isolation sign posted on the door facing of Resident #41's room. When Nurse Aide (NA) #52 opened the door to the room to go in and demonstrate how she applied personal protective equipment (PPE), NA #4 was standing by Resident #41, who was sitting on the commode. NA #4 was wearing no PPE. Upon request, Quality Standard Coordinator #69 (QSC) came to Resident # 41's room. When asked whether NA #4 should have PPE on, the QSC and NA #52 both stated, Yes. NA #52 and the QSC informed NA #4 to leave the room and put her PPE on before going into the room again. NA #4 walked out into the hall without washing her hand and proceeded to put on an isolation gown. She stated, I am sorry. The DON then arrived, and informed those present that Resident #41 had Clostridium difficile (C-diff) and the NA should have known to put her PPE on prior to entering the room. The DON stated, The information on the door tells the staff to put on a gown, gloves and mask if they came in contact with such fluids. The DON stated, NA #4 had just started working here on Monday, and she did her orientation training related to PPE on 06/29/15. A review of the progress notes on 07/01/15 at 1:00 p.m., revealed Unit Charge Nurse-Registered Nurse (UCN-RN) #6 wrote a note on 06/28/15 stating Resident #41 was having chronic diarrhea, heme (hemoccult - test for hidden blood) the resident's stools three (3) times. Resident #41's stools are black, liquid tarry stools. Nurse Practitioner (NP) #68 gave the UCN-RN an order to obtain a stool sample for culture to determine what infection she might have. The stool culture was collected on 06/28/15. The result from the stool culture was positive for Clostridium difficile (C-diff) (a spore forming bacterium- causing an infectious diarrhea). Resident #41 was placed on [MEDICATION NAME] 250 milligram (mg) one capsule by mouth three (3) times a day for recurrent[DIAGNOSES REDACTED] for thirty (30) days. The medication was started on 06/29/15. The resident was also placed on [MEDICATION NAME] (an antibiotic) 550 mg two (2) times a day for recurrent[DIAGNOSES REDACTED] for thirty (30) days. @ A review of the NAs' Kardex and care plan for Resident #41 on 07/01/15 at 1:05 p.m., found both included the instruction, Transmission based precautions -Follow directions posted on room door. A review of the new employee orientation record for NA #4, on 07/01/15 at 2:30 p.m., revealed the NA received her training on isolation precautions on 06/29/15 from the DON. A review of what the facility referred to as its infection-control practice, on 07/01/15 at 2:45 p.m., revealed the staff would wear appropriate personal protective equipment (gloves, gown, mask, eyewear, etc., as necessary) to prevent exposure to spills or splashes of blood or other potentially infectious materials. A review of the facility's operations policy on 07/01/15 at 2:50 p.m., revealed, When transmission-based precautions are assigned to a patient, approved signage shall be used on the outside of the patient's room door that identifies the expanded precautions required. All personnel shall follow the hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. The operation's policy also stated that employees must wash their hands using soap and water under the following conditions: Before and after enter infection precaution settings The DON on 07/01/15 at 3:00 p.m., stated, We have provided retraining to NA #4 on isolation precautions. b) Resident #23 On 06/30/15 at 3:17 p.m., a review of the (MONTH) (YEAR) infection control log showed the onset of the resident's infection as 05/12/15. However, it showed that a culture was obtained on 05/10/15. The infection site was marked three (3) indicating it was a urinary tract infection (UTI) organism, and marked two (2) indicating the organism was Escherichia coli (E coli). The antibiotic [MEDICATION NAME] was given for the UTI. The log showed the infection was cleared on 05/23/15. On 06/30/15 at 3:33 p.m., review of the (MONTH) (YEAR) infection control log found it was marked to show the onset of infection as 06/02/15; however, it showed that a culture was obtained on 05/26/15. The infection site was marked three (3) indicating it was an UTI (urinary tract infection) organism. The organism was marked to indicate E coli. The antibiotic [MEDICATION NAME] was given for the UTI. The log showed the infection was cleared on 06/03/15 (the day after the onset). At 10:22 a.m. on 07/02/15, a review of Physician orders [REDACTED]. Review of the medication administration record (MAR) revealed [MEDICATION NAME] was started on 05/30/15 and was given for 10 days as ordered, with the last dose being given on 06/08/15. An interview took place on 07/02/15 at 11:26 a.m. with the director of nurses (DON) and Quality Standards Coordinator Registered Nurse (RN) #69, concerning the accuracy of the month of (MONTH) and (MONTH) (YEAR) infection control logs. After reviewing the medical records, the DON and the Quality Standards Coordinator both agreed the (MONTH) (YEAR) and (MONTH) (YEAR) infection control logs had inaccurate entries for Resident #23. The (MONTH) (YEAR) infection control log showed the onset of infection as 05/12/15 and showed a culture was obtained on 05/10/15; however, it should have shown the onset of infection as 05/10/15 and culture obtained on 05/12/15. The Quality Standards Coordinator said the (MONTH) (YEAR) log was marked with an incorrect date when the infection cleared, . it was not 06/03/15 but should have been 06/09/15, the day after the last dose of antibiotics was given. The infection control logs were corrected after surveyor intervention. c) Resident #55 Review of medical records, at 12:03 p.m. on 07/01/15, revealed Resident #55 had several urinary tract infections (UTI) with UA (urinalysis) and C&S (culture and sensitivity) obtained on 05/26/15, 03/11/15, and 03/09/15. Medical records revealed antibiotics were given to treat the urinary tract infections. A nurse's progress note, dated 05/29/15, revealed resident had a viral vaginal infection with light green and yellow drainage, foul odor; no s/s (signs/symptoms) pain upon urination, resident c/o pain and burning to lesions upon observation. On 07/01/15 at 9:57 a.m., review of physician order [REDACTED]. The culture was obtained on 05/24/15. On 07/01/15 at 12:38 p.m., the infection control logs for the (MONTH) (YEAR) and (MONTH) (YEAR) were reviewed. There was no entry on the infection control logs for a viral vaginal infection for Resident #55. In an interview on 7/01/15 at 12:42 p.m., when asked why Resident #55's viral vaginal infection was not on the infection control logs, the director of nursing (DON) stated she would look into it. The DON returned with an amended (MONTH) infection control log that included the vaginal infection, and confirmed it should have been on the log. d) Review of the facility's infection control program operations policy on 07/02/15 at 11:30 a.m., revealed in the section titled Policy Statements, The facility will develop, implement and maintain an infection control program to prevent, identify, and contain, to the extent possible, the onset and spread of microorganisms in the facility. The facility's infection control program will: a. Perform surveillance and investigation to prevent, to the extent possible, the onset and spread of infection. To comply with the facility's policy accurate and complete infection control data would be needed.",2018-07-01
5902,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2015-07-02,514,D,1,0,DYHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the accuracy of the medical record for one (1) of six (6) sampled residents. A verbal order to obtain a urine sample using a straight catheter for Resident #55, was not written and placed in residents' clinical record. Resident identifier: #55. Facility census: 54. Findings include: a) Resident #55 An interview with Licensed Practical Nurse (LPN) #48 and Director of nurses (DON) #26, at 12:19 p.m. on 07/02/15, revealed Resident #55 had a urinary tract infection [MEDICAL CONDITION]. The LPN stated there was an order to use a straight catheter to get a urine specimen for a UA (urinalysis) and C&S (culture and sensitivity). LPN #48 stated she had assisted Registered Nurse (RN) #06 to get the urine specimen. When the urine specimen was obtained, the odor and color were noted, the nurse practitioner was notified, and a new order was given to send the resident out to the hospital. During the interview, LPN #48 became unsure how the urine specimen was actually obtained, whether it was obtained by clean catch or by using a catheter. She stated RN #06 got the urine specimen and passed the specimen cup to her and she noted the odor and color of the specimen, but did not remember how RN #06 obtained it. The DON checked the medical records to see if she could find the order concerning the urine specimen. RN #06 was called, and a message was left on her phone to call the facility. On 07/02/15 at 1:07 p.m., the DON said she was missing the order for a UA and C&S for Resident #55. The urine specimen was obtained, and the UA and C&S results were in the medical record, however, no order for the tests could be found. A telephone interview with RN #06, on 07/02/15 at 1:55 p.m., with the DON and the Vice President of Compliance present, revealed the following: RN #06 stated she forgot to write the verbal order the nurse practitioner gave to obtain a UA & CS on Resident #55. RN #06 stated she had spoken by phone several times that afternoon with the nurse practitioner concerning Resident #55. RN #06 said the nurse practitioner did give a verbal order to obtain a UA & C&S from Resident #55, and to use a straight catheter if necessary to obtain the urine specimen. RN #06 said she explained the straight catheter procedure to the resident, and the resident consented prior to her obtaining the urine specimen.",2018-07-01
6322,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2014-07-23,252,E,0,1,5EN111,"Based on observation and staff interview, the facility failed to ensure the environment where residents live was comfortable and homelike. The area designated as a resident sitting area was in the corner area of the dining room. It contained rocking chairs, a sofa, and a television. Empty wheelchairs and geri-chairs were observed stored in front of the furniture preventing access to residents or visitors who desired to sit in these chairs. The residents who were seated in their wheelchairs were sitting in an area where the empty wheelchairs were stored. This did not create a pleasant homelike sitting area. This practice had the potential to affect more than an isolated number of residents. Facility Census: 55. Findings include: a) During an observation on 07/15/14 at 8:00 a.m., the area in the corner of the dining room was observed. This area had carpet, a television, a couch, and several rocking chairs. It was designated as a sitting area where residents could sit and/or watch television. Eight (8) empty wheelchairs were observed stored in the area, blocking access to the rocking chairs and the sofa. On 07/16/14 at 4:00 p.m., nine (9) empty wheelchairs and four (4) empty geri-chairs were observed stored in the dining room. Six (6) of the empty chairs were in the television area in front of the rocking chairs. This prevented access to the area by any resident who desired to sit in the rocking chairs or on the couch. During a confidential employee interview, a nursing assistant was questioned about the chairs being stored in the resident sitting area in the corner of the dining room. The nursing assistant replied, That is where they told us we have to put them. The dining area was observed on various days and times during the survey from 07/15/14 to 07/23/14. There were always several wheelchairs and geri-chairs stored in the resident sitting area. A tour was conducted with the Environmental Service Supervisor (Employee #23) and the facility administrator (Employee #78) on 07/23/14 at 12:00 p.m. They were made aware of the observations, throughout the survey, of the chairs stored daily in the residents' sitting area. They agreed this was not a homelike environment.",2018-04-01
6323,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2014-07-23,253,D,0,1,5EN111,"Based on observation and staff interview, the facility failed to ensure effective housekeeping and maintenance services. Four (4) rocking chairs and a geri-chair in the common area designated as a sitting area for residents, were observed with tears, rips, and/or with stuffing of the upholstery exposed. The condition of these items rendered them unable to be effectively sanitized. This practice had the potential to affect more than an isolated number of residents. Facility Census: 55 Findings include: a) On 07/15/14 at 8:00 a.m., four (4) rocking chairs and a geri-chair were observed with tears and rips in the upholstery, and the stuffing was exposed around the bottom parts of the chairs. A tour was conducted with the Environmental Service Supervisor (Employee #23) and the facility Administrator (Employee #78), on 07/23/14 at 12:00 p.m. Observations were made of the four (4) rocking chairs and the geri-chair. They agreed the condition of the rocking chairs and the geri-chair upholstery could result in improper sanitization of the chairs.",2018-04-01
6324,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2014-07-23,272,D,0,1,5EN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview, the facility failed to complete an accurate comprehensive assessment for one (1) of three (3) residents reviewed in Stage 2 for dental services. The minimum data set (MDS) assessment did not indicate the resident had [MEDICAL CONDITION] on his lower lip. Resident identifier: #14. Facility census: 55 Findings include: a) Resident #14 Resident #14 was admitted to the facility on [DATE]. During an interview with the resident, on 07/15/14 at 9:30 a.m., four (4) black round [MEDICAL CONDITION] were observed on the resident's lower lip. The resident said he believed the spots were from smoking. Review of the resident's admission MDS, with an assessment reference date of 05/21/14, found Section L, related to dental status, did not indicate the resident had [MEDICAL CONDITION] on his lower lip. The failure to indicate the [MEDICAL CONDITION] on the MDS was brought to the attention of the director of nursing (DON). At 1:07 p.m. on 07/23/14, the DON confirmed the [MEDICAL CONDITION] were not identified on the resident's MDS.",2018-04-01
6325,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2014-07-23,332,D,0,1,5EN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, the facility failed to ensure a medication error rate of less than five (5) percent. Resident #33's eye drops were not instilled to make contact with the conjunctival sac, and was not washed over the eye for optimal absorption. Also, Resident #13 did not receive the specific Calcium preparation as ordered by the physician. Two (2) errors, of the thirty-one (31) opportunities observed, resulted in a medication error rate of 6.45%. This practice affected two (2) of five (5) residents observed during medication administration observations. Resident identifiers: #13 and #33. Facility Census: 55. Findings include: a) Resident #13 During medication administration observation, on 07/17/14 at 8:30 a.m., Employee # 24 administered one (1) Calcium 600 mg (milligram) + D tablet by mouth to Resident #13. Review of the physician's orders [REDACTED]. The medication observed administered by the nurse was not the same as that ordered by the physician. b) Resident #33 During medication administration observation, on 07/17/14 at 9:20 a.m., Employee #24 was observed administering an eye drop medication, [MEDICATION NAME] ([MEDICATION NAME]) one (1) drop to each eye. The nurse (Employee #24) pulled the resident's upper eyes open from the eye brows and instilled the drop in each eye from the top. Observation revealed the drops did not make full contact with the eye. The facility policy titled Instillation of Eye Drops was reviewed on 7/18/14. The section stated Steps in the Procedure stated: Step 7- Gently pull the lower eyelid down. Instruct the resident to look up. Step 8- Drop the medication into the mid lower eyelid (fornix). Step 9- Instruct the resident to slowly close his/her eyelid to allow for even distribution of the drops. These steps were not performed when Employee #24 administered the eye drops. On 7/23/14 at 11:00 a.m., the Director of Nursing was made aware of the technique observed for administration of the eye drops. She stated this was not the proper way to administer eye drops. She also stated in-service training for Employee #24, on the procedure for properly administering eye drops, had already been completed.",2018-04-01
6326,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2014-07-23,356,B,0,1,5EN111,"Based on Review of the POS [REDACTED]. This practice had the potential to affect more than an isolated number of residents. Facility census: 55. Findings include: a) Review of the facility's posted nursing staffing information, on 07/11/14 , indicated three (3) registered nurses were working the day shift. Review of the staff schedule indicated only one (1) registered nurse was scheduled for direct care on 07/11/14. This information was reviewed with Employee # 76, the director of nursing (DON), on 07/23/14 at 11:00 a.m. She stated, The nurse who filled this out must have counted me and the other nurse. The other nurse was identified as the minimum data set assessment nurse. The DON confirmed she and the MDS nurse were not performing direct care that day, and should not have been counted on the posting.",2018-04-01
6327,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2014-07-23,371,E,0,1,5EN111,"Based on observation and staff interview, the facility failed to ensure food was prepared and served under sanitary conditions. Beverages were prepared for service in a manner which created the potential for food contamination. Non-food items that came in direct contact with food items were touched after non-food items, without handwashing after touching the non-food items and before touching food contact items. This practice had the potential to affect more than an isolated number of residents who were served the beverages. Facility Census: 55. Findings include: a) On 7/22/14 at 12:10 p.m., Employee #48, dietary service assistant, was observed in the kitchen, placing ice cylinders (tubes filled with ice placed inside a pitcher to keep the beverage cold) into eight (8) pitchers of beverages. These beverages were to be served with the lunch meal. Observations revealed a dietary employee passed each filled ice cylinder to Employee #48. Employee #48 handled the ice cylinders with her bare hands, then placed them inside the pitchers of beverages. While retrieving the ice cylinders, Employee #48 opened the cooler door three (3) different times and touched the handle of the cart on which the beverages were placed, four (4) different times with her bare hands. She did not wash her hands between touching potentially contaminated surfaces and the ice cylinders. The dietary service assistant touched areas on the ice cylinders that were submerged into two (2) pitchers of milk and two (2) pitchers of cranapple juice. With bare hands, Employee #48 also touched the upper inside part of the cylinders that could come in contact with the beverages in the pitchers when they were transported or as the beverages were poured from the pitchers. On 7/22/14 at 12:25 p.m., an interview with Employee #48 revealed she was aware she touched the cooler door handle and the beverage cart handle several times while preparing the beverages for the lunch meal. She stated, . yes, I should have washed my hands . after I touched something else.",2018-04-01
6328,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2014-07-23,425,E,0,1,5EN111,"Based on observation, policy review, and staff interview, the facility, in collaboration with the consultant pharmacist, failed to coordinate the provision of pharmacy services. There was not an effective process for the disposition of outdated medications in the medication room. In addition, medications were not discarded according to facility policy. This practice had the potential to affect more than an isolated number of residents in the facility. Facility Census: 55. Findings include: a) Observation of the facility medication room, with Registered Nurse #5, on 07/17/14 at 10:00 a.m., found the following outdated medications: [REDACTED] 1. Docusate Sodium liquid 60 mg /15 ml (milligrams per milliliter); two (2) sixteen ounce (16 oz) bottles with an expiration date of 06/14. 2. Ocu-Soft eye lid cleanser pads - one (1) box with an expiration date of 06/14. 3. Pneumococcal Vaccine vial with an open date of 05/21/14. 4. Five (5) bottles of Fluvirin 2013-2014 vial house stock (flu vaccine), which expired 03/14 5. Lorazepam 2 mg/10 ml; three (3) vials (in refrigerator); expiration date 05/14. 6. Tuberculin purified protein vials opened. No date indicating when opened. 7. Three (3) bags Vancomycin in the refrigerator - 250 ml 0.9% sodium chloride mixed with Vancomycin 100 mg /ml. 1500 mg (15 ml) per bag; expiration date 06/14/14. Employee #5 verified the outdated medications and removed them from the medication supply. She also verified the facility practice for opening vials was to discard them 30 days after the date they were opened. A review of the facility's medication policy, Section 4.1, titled Medication Storage, found in Section 14, Outdated medications, contaminated, discontinued, or deteriorated medications are to be removed immediately from stock and disposed of according to the procedures for medication disposal.",2018-04-01
6329,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2014-07-23,431,D,0,1,5EN111,"Based on observation and staff interview, the facility failed to ensure medications were properly labeled. An inhaler was observed in a cup in the bottom drawer of the medication cart. There was no name to indicate who the inhaler belonged to and no instructions for its use. Facility Census: 55. Findings include: a) During a medication administration observation, on 07/16/14 at 4:55 p.m., the nurse (Employee #40) opened the bottom drawer of the medication cart. A hand held breathing inhalation aerosol container was observed in a cup in the drawer. There was no resident name on the inhaler, no indication for whom it was to be used, and no instructions for use. The medication had no label. It simply stated the name of the inhaler Qvar 80 mg. Employee # 40 was interviewed about the inhaler. He verified it should have a box containing this information, but he did not know what happened to it. He immediately removed the inhaler from the medication cart. He stated he thought it belonged to Resident #87, and a new one would be ordered.",2018-04-01
6330,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2014-07-23,520,F,0,1,5EN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility's quality assurance (QA) committee failed to identify and address quality deficiencies of which it was aware or should have been aware. The QA committee failed to identify the need to develop and implement processes to ensure medications were properly and safely administered and stored. This practice had the potential to affect all residents in the facility. Facility Census: 55. Findings include: a) Medication Administration During medication administration on [DATE] at 8:30 a.m. with a nurse, Employee #24, two (2) medication errors were observed. This resulted in a medication error rate of 6.45%. Resident #13 was administered Calcium 600 mg + D. The physician order was Calcium 600 mg by mouth daily. The combination of Calcium with vitamin D was not ordered for this resident. An observation of administration of eye drops to Resident #33 revealed the drops were not properly instilled to ensure complete absorption. Nurse #24 pulled the resident's upper eye lids open from the eye brows and instilled the drop into the eyes from the top. The drop was observed to not make full contact with the eyes. The facility policy titled Instillation of Eye Drops was reviewed [DATE]. The section stated Steps in the Procedure were: Step 7- gently pull the lower eyelid down. Instruct the resident to look up. Step 8- Drop the medication into the mid lower eyelid (fornix). Step 9- Instruct the resident to slowly close his/her eyelid to allow for even distribution of the drops. These steps were not performed when administering the eye drops. b) Disposal of Outdated Medications Observation of the facility medication room, with the Registered Nurse #5, on [DATE] at 10:00 a.m., found the following outdated medications: [REDACTED] 1. [MEDICATION NAME] Sodium liquid 60 mg /15 ml; two (2) sixteen ounce (16 oz) bottles with an expiration date of ,[DATE]. 2. Ocu-Soft eye lid cleanser pads- one (1) box with an expiration date of ,[DATE]. 3. Pneumococcal Vaccine vial with an open date of [DATE]. 4. Five (5) bottles of [MEDICATION NAME] ,[DATE] vial house stock (flu vaccine) expired ,[DATE] 5. [MEDICATION NAME] 2 mg/10 ml; three (3) vials (in refrigerator); expiration date ,[DATE]. 6. [MEDICATION NAME] purified protein vials opened. No date indicating when opened. 7. Three (3) bags [MEDICATION NAME] in the refrigerator - 250 ml 0.9% sodium chloride mixed with [MEDICATION NAME] 100 mg /ml. 1500 mg (15 ml) per bag; expiration date [DATE]. Review of the facility policy for medication storage, Section 4.1 titled Medication Storage, indicated in section 14: Outdated medications, contaminated, discontinued, or deteriorated medications are to be removed immediately from stock and disposed of according to the procedures for medication disposal. Employee #5 verified the outdated medications and removed them from the medication supply. She also verified the facility practice for opening vials was to discard them 30 days after the date they were opened. c) During an interview with the administrator (Employee # 78), on [DATE] at 3:00 p.m., she was questioned about the Quality Assurance Committee. She said the pharmacist attended the QA meetings only on occasion. She stated the QA committee had not not identified issues with medication storage or administration.",2018-04-01
7563,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-02-13,246,D,0,1,HJDH11,"Based on observation and staff interview the facility failed to ensure one (1) of 40 residents reviewed in stage I was accommodated in a matter that allowed access to needed equipment. The resident ' s call light was not within her reach and it did not function properly. Resident identifier: #8. Facility census: 55. Findings include: a) Resident #8 On 02/05/13 at 9:00 a.m., an observation of the call system in Resident #8 ' s room revealed the resident ' s call light was not within her reach. The call light was on the floor, out of her reach. In addition, the call light did not function properly. When the resident pushed the call light, it did not beep on the nursing staffs ' pager. Further observation revealed the resident was capable of pushing the call button to ask for assistance. On 02/13/134 at 1:00 p.m., the director of maintenance stated he had determined a problem with the resident ' s call light. The maintenance director said he had recently changed the battery inside the call system and he had not ensured call system button was reset.",2017-04-01
7564,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-02-13,253,D,0,1,HJDH11,"Based on observation and staff interview, the facility failed to ensure all fixtures and furnishings in residents' rooms were in good repair. Four (4) of forty (40) residents had fixtures/furnishings in their rooms which were unclean or in poor repair. Resident identifiers: #40, #50, #70, and #28. Facility census: 55. Findings include: a) Resident #40 On 02/05/13 at 1:52 p.m., Resident #40's room (Room #D-6) was observed to have a soiled privacy curtain. The curtain had a circular stain on the fabric. On 02/13/13 at 12:25 p.m., further observation revealed the curtain still had a circular stain on the fabric. b) Resident #50 On 02/05/13 at 8:50 a.m., Resident #50's room (Room # C-7) was found to have scratches along the wall. On 02/13/13 at 12:30 p.m., revealed these scratches were still present. c) Resident #70 On 02/04/13 at 2:37 p.m., Resident #70's room (Room # C-11) had a wardrobe with scuffs and scratch marks on the finishing. On 02/13/13 at 12:35 p.m., an observation revealed these scratches and scuffs were still on the wardrobe's finishing. d) Resident #28 On 02/05/13 at 10:18 a.m., Resident #28's room (Room #C-6) had black scuff marks along the bottom of the wall in the bathroom (near the nightlight). The toilet in Room #C-6's bathroom had a toilet safety seat. The legs on the safety seat were not secure. On 02/13/13 at 12:40 p.m., a second observation revealed black scuff marks along the bottom of the bathroom wall as well as an unsecured toilet safety seat. e) The environmental supervisor (Employee #24) accompanied the tour on 02/13/13 at 12:25 p.m. He verified the issues existed with cleanliness and conditions the fixtures and furnishings in these rooms.",2017-04-01
7565,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-02-13,280,E,0,1,HJDH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on care plan review, medical record review, review of incident and accident reports, and staff interview, the facility failed to ensure care plans were updated and revised to reflect the resident's current quality of care and quality of life needs. Five (5) of 28 residents whose care plans were reviewed, had care plans that did not reflect their current problematic areas or the interventions used to try to achieve the goals. Care plans had not been revised to address changes in activities, [MEDICAL CONDITION], contractures, activities of daily living, and falls. Resident identifiers: #31, #72, #46, #56, and #6. Facility census: 55. Findings include: a) Resident #31 On 02/06/13 at 10:00 a.m., a review of the facility's incident and accident reports revealed the resident sustained [REDACTED]. The report stated a nurse aide found the resident sitting on her bottom between the two (2) beds in the room. Her left leg was bent backwards, underneath her. She denied pain and had no observed injuries. The care plan review for Resident #31 revealed the facility established a care plan based on the resident having a history of falls prior to her admission to the facility on [DATE]. The care plan was not updated to reflect the resident had experienced an actual fall and no pertinent interventions relevant to the circumstances of the fall were established. During an interview with the resident nursing assessment coordinator (Employee #74) and the resident nursing assessment coordinator consultant, on 02/06/13 at 11:00 a.m., it was confirmed the facility had not updated the care plan to reflect the resident had sustained falls since admission to the facility. b) Resident #46 Review of the care plan for Resident #46, on 02/07/13 at 10:45 a.m., found this resident had a care plan for [MEDICAL CONDITION]. The care plan also listed the resident was receiving [MEDICATION NAME] to assist with [MEDICAL CONDITION]. When reviewed, the physician's orders [REDACTED]. On 02/07/13 at 1:50 p.m., Employee #75 (director of nursing) confirmed the care plan was not revised after the [MEDICATION NAME] was discontinued. c) Resident #72 Medical record review, conducted at 11:00 a.m. on 02/12/13, revealed the resident had contractures of both hands, both shoulders, and both knees. Review of therapy records, at 12:00 p.m. on 02/12/13, revealed the resident received Occupational Therapy (OT) and Physical Therapy (PT) for the following dates: OT/PT - 9/21/10 - 10/5/10 PT - 2/17/11 - 3/18/11 OT - 9/29/11 - 10/17/11 PT - 11/11/11 - 12/15/11 - 1/6/12 OT - 12/14/11 - 12/30/11 OT - 5/8/12 - 6/15/12 The resident currently had bilateral hand splints. Nursing assistant (NA) staff were inserviced on the proper placement of the splints on 10/14/11 and 10/17/11. The resident last received therapy services on 06/15/12. An interview with two (2) NAs, Employee #81 and Employee #8, was conducted 2:00 p.m. on 02/12/13. The NAs stated range of motion (ROM) was completed daily on all residents with morning care, but this was not documented. They stated if the resident had a specific area for ROM, then it was recorded in the Kiosk, the method used to inform NAs of care plan interventions. Although therapy was discontinued on 06/15/12, the facility did not update the care plan or the Kiosk to include ROM until 02/04/13. This was discussed with Employee #77, a registered nurse (RN), at 2:00 p.m. on 02/12/13. Additionally, the contractures identified in the care plan were to the resident's hands bilaterally. The facility had not updated the care plan to reflect the resident's contractures of the shoulders or the knees. d) Resident #6 Review of the care plan for this resident revealed it was not revised to reflect the interventions currently being provided to address a vision problem. The care plan identified a problem of self care performance deficit with activities of daily living, which included vision. The interventions were Has glasses to wear when reading but usually does not, impaired vision without glasses. Additionally the care plan of 01/26/13 stated a separate problem of impaired visual function, sees large print. The interventions were, Arrange consultation with eye care practitioner as required, if resident/family desires; fall risk due to visual impairment-maintain arrangement of furniture and personal items in room in order to promote independence and safety. Ensure patient is aware whenever items are rearranged or removed . Encourage to wear glasses. Is able to read only large print, sees well in well lit room. According to the activity director, Employee #34, during an interview on 02/12/13 at 9:15 a.m., the resident's husband reads to the resident, and she did not use glasses or large print material. The care plan was not updated to reflect her husband read to her, or that large print material was no longer provided. Employee #77, a registered nurse, also verified, on 02/12/13 at 9:40 a.m., the care plan should be revised to show the changes to the activity provided, which now included involvement by the husband. e) Resident #56 This resident was identified on a significant change Minimum Data Set (MDS) assessment, dated 10/25/12, as needing extensive assistance with toileting, at times requiring the assistance of two (2). The care area assessment (CAA) worksheet also indicated, under activities of daily living (ADL) care for toileting, The patient currently requires extensive assistance of two (2). A nursing assessment, dated 01/22/13, indicated the need for one (1) person physical assistance with transfers on and off the toilet. Interview with an NA, Employee #58, on 02/06/13 at 2:15 p.m., revealed staff only used one (1) person assist when assisting the resident to the toilet. The MDS nurse, Employee #77, at 8:34 a.m. on 02/07/13, also verified staff only provided one (1) person assist. The existing care plan stated the resident required the assistance of two (2) staff for toileting. The care plan was not revised to reflect the change in the amount of assistance required to toilet the resident, until this was brought to the attention of staff on 02/07/13, during the survey.",2017-04-01
7566,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-02-13,282,D,0,1,HJDH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure the care plan was implemented for one (1) of twenty-eight (28) residents whose care plans were reviewed. The resident was not provided a treatment for [REDACTED]. Resident identifier: #52. Facility census: 55. Findings include: a) Resident #52 Observation of Resident #52, on 02/06/13 at 10:19 a.m., found the skin on this resident's face was dry, flaky and red. Review of the medical record identified the resident was ordered [MEDICATION NAME] shampoo three (3) times per week and [MEDICATION NAME] cream was to be applied to his face twice a day related to seborrheic [MEDICAL CONDITION]. The physician orders [REDACTED]. Review of the shower schedule found this resident received two (2) showers a week on Tuesdays and Fridays. During interviews with two (2) nursing assistants, Employee #8 and Employee #51, on 02/06/13 at 1:15 p.m., it was confirmed the resident did not receive three (3) showers a week, he only received two (2). Review of the care plan found the plan included the resident was to receive [MEDICATION NAME] shampoo three (3) times a week on shower days. During an interview with Employee #75 (director of nursing), on 02/06/13 at 12:39 p.m., it was verified the resident was not receiving the [MEDICATION NAME] shampoo three (3) times a week, as indicated in the care plan.",2017-04-01
7567,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-02-13,309,D,0,1,HJDH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and medical record review, the facility failed to provide services for residents to ensure optimum physical, mental and/or psychosocial well-being for three (3) of twenty-eight (28)sample residents. One resident was not provided skin treatments with showers as ordered by the physician, a resident complained of mouth pain which was not addressed by the facility, and a resident was not monitored related to a B 12 deficiency. Resident identifiers: #52, #8, and #72. Facility census: 55. Findings include: a) Resident #52 Observation of Resident #52, on 02/06/13 at 10:19 a.m., found the skin on this resident's face was dry, flaky and red. Review of the medical record identified this resident was ordered [MEDICATION NAME] shampoo three (3) times per week, and [MEDICATION NAME] cream to his face twice a day related to seborrheic [MEDICAL CONDITION]. The physician's orders [REDACTED]. Review of the shower schedule found this resident received two (2) showers a week, on Tuesdays and Fridays. Review of the resident's care plan found this resident had a care plan to receive [MEDICATION NAME] shampoos three (3) times a week on shower days. During interviews with two (2) nursing assistants, Employee #8 and Employee #51, on 02/06/13 at 1:15 p.m., it was discovered the resident did not receive three (3) showers a week, but was provided only two (2) showers a week. Employee #75 (director of nursing), was interviewed on 02/06/13 at 12:39 p.m. She verified the care plan did not correlate with the physician orders, and the resident was not receiving the treatment of [REDACTED]. In addition, review of the facility's treatment administration records (TAR) revealed staff signed that the resident had showers (for treatments with [MEDICATION NAME] shampoo) on days he did not receive a shower. For the months of November 2012 and December 2012, nurses documented the resident had twenty-two (22) showers he actually did not receive. Employee #75 (director of nursing) was interviewed on 02/06/13 at 2:59 p.m. She confirmed these documented showers did not accurately reflect the number of showers the resident was provided in November 2012 and December 2012. . b) Resident #8 On 02/04/13 at 3:00 p.m., Resident #8 stated her gums were hurting. The medical record review, conducted on 02/07/13, revealed a physician's orders [REDACTED]. The resident had received [MEDICATION NAME] on a prn (as needed) basis. The care plan addressed the resident's oral discomfort, and interventions to resolve this issue were initiated on 11/19/12. The interventions included a dental consult as needed. A progress note, dated 01/10/13 included, Spoke with (name) and (dentist's name) is out of town until Monday but she will make him aware of (Resident #8's) gums hurting and he will stop and see her. The facility had no evidence to show the dentist came to the facility to see the resident. There was also no evidence the facility tried to contact the dentist after 01/10/13. On 02/07/13 at 11:30 a.m., the director of nursing (Employee #75) reviewed the resident's medical record. This review revealed the resident complained of mouth pain in October, November, and December 2012, and January 2013. On 02/07/13 at 11:50 a.m., the director of nursing contacted the scheduler of medical appointments (Employee #21). The director of nursing said the dentist would come by the facility and see the resident. She verified the dentist had not come to the facility to see the resident in October, November, and December 2012, or in January or February 2013. c) Resident #72 Review of the medical record for Resident #72, at 11:15 a.m. on 02/11/13, revealed the resident received a Vitamin B 12 injection every month for the [DIAGNOSES REDACTED]. The resident had no plan of care in place regarding the Vitamin B 12 deficiency, lab monitoring, nor the expectations of the resident's response to therapy. An interview with Employee #75, a registered nurse (RN), Director of Nursing Services (DON), was conducted at 11:45 a.m. on 02/11/13. Employee #75 confirmed, after reviewing the resident's record, there was no care plan for the Vitamin B 12. She confirmed a need for appropriate lab monitoring to monitor the resident's Vitamin B 12 levels and monitoring the resident's response to therapy. A telephone interview was conducted, at 12:25 p.m. on 02/11/13, with Employee #84, the consultant pharmacist for the facility. Employee #84 advised a resident on Vitamin B 12 injections should have orders in place for a Complete Blood Count (CBC) every six (6) months, as well as a Vitamin B 12 level once yearly. After the conversation with the DON on 02/11/13, orders for B 12, CBC and Comprehensive Metabolic Profile (CMP) every six (6) months were added to the resident's orders.",2017-04-01
7568,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-02-13,312,D,0,1,HJDH11,"Based on medical record review, review of information from the kiosk (used to record and communicate information about care) and staff interviews, the facility failed to ensure one (1) of twenty-eight (28) Stage II sample residents were provided services to maintain good personal hygiene. A resident who was unable to shower herself independently was not provided showers as scheduled. Resident identifier: #34. Facility census: 55. Findings include: a) Resident #34 Review of the medical record for Resident #34, on 02/07/13, revealed she was scheduled for showers three (3) times each week. Records were reviewed from September 2012 through February 2013. Of the sixty-nine (69) opportunities for a shower, the records indicated thirty-one (31) times Resident #34 did not receive a shower. Review of shower documentation from the nursing assistant kiosk for Resident #34, on 02/12/13 revealed the following; -- October 2012 - nine (9) days without a shower from 10/13/12 to 10/22/12, total of seven (7) showers. -- November 2012 - fourteen (14) days without a shower from 10/29/12 to 11/12/12, total of four (4) showers. -- December 2012 - eleven (11) days without a shower from 12/20/12 to 12/31/12, total of seven (7) showers. -- January 2013 - seven (7) days without a shower from 01/01/2013 to 01/07/2013 and seven (7) days from 01/14/13 to 01/21/13, total of seven (7) showers. -- February 2013 - seven (7) days without a shower from 01/31/13 to 02/07/13, total of two (2) showers for twelve (12) days. According to the facility shower sheets, the resident did not receive a shower thirteen (13) of fifty-one (51) times the resident should have received a shower from 09/01/12 to 02/11/2013. In an interview with Employee #73 (Registered Nurse), on 02/12/13 at 12:00 p.m., showers were discussed. She stated that the showers had been an issue at one time, but the facility had worked that out. On 02/12/13 at 12:05 p.m., an interview with Employee #75 (director nursing service) confirmed there were past shower schedule issues. She checked a PRN (as necessary) schedule and could find no further evidence of received showers for Resident #34.",2017-04-01
7569,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-02-13,315,D,0,1,HJDH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review. and staff interview, the facility failed to assist a resident in maintaining the the highest level of bladder function possible. A resident who had been continent, was assessed as having become occasionally incontinent. The facility failed to implement a program in an attempt to restore the resident's former bladder function. Additionally, the facility failed to ensure a resident's catheter tubing was positioned in a manner to prevent the spread of infection to the resident while the resident ambulated in the hallway. This was evident for two (2) of five (5) residents who required the use of a catheter out of a sample of 28 in the Stage II sample. Resident identifiers: #5 and #72. Census: 55 Findings include: a) Resident #72 Review of the admission minimum data set (MDS) assessment, for Resident #72, dated 11/02/12, was conducted at 9:32 a.m. on 02/12/13. The resident was coded as always continent for bladder function. Review of the resident's most current MDS, dated [DATE], revealed the resident was coded as occasionally incontinent for bladder function. Review of the care plan, on 02/12/13 at 9:40 a.m., revealed there was no care plan in place for the resident's occasional urinary incontinence. Interview with the corporate MDS coordinator, Employee #77, a registered nurse (RN), was conducted on 02/12/13 at 9:45 a.m She was advised the resident was coded occasionally incontinent on her latest MDS dated [DATE], but there was no care plan in place to address the onset of occasional urinary incontinence. Employee #77 advised she was going to check on the issue. At 9:58 a.m. on 02/12/13, Employee #77, reported there was no care plan in place to address the resident's occasional incontinence. She advised she was going to initiate a three (3) day voiding trial on the resident, as well as update the care plan to address the incontinence. Employee #77 also advised at that time that the resident wore a brief. There was no evidence the facility had taken steps to attempt to restore this resident's bladder function. b) Resident #5 This resident was observed, on 02/05/13 in the afternoon, ambulating in the hallway in a wheelchair near the nursing station. The resident's catheter tubing was in direct contact with the floor. Employee #36, the unit charge nurse, a licensed practical nurse, was alerted to the issue at that time. She returned the resident to her room to readjust the tubing. This resident was known to have [MEDICAL CONDITION] and was admitted to the hospital in October 2012 with a [DIAGNOSES REDACTED]. The tubing in direct contact with the floor created an opportunity for transfer of microorganisms to the resident's urinary tract for this resident who was susceptible to urinary tract infections.",2017-04-01
7570,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-02-13,353,E,0,1,HJDH11,"Based on observation and staff interview, the facility failed to deploy nursing personnel in a manner which ensured resident services were provided in a timely manner. The 10:00 a.m. supplements/snacks were observed being provided at 11:39 a.m. At that time, the noon meal service had already begun. This practice affected more than a limited number of residents. Resident identifiers: #11, #34, #55, #37, #21, #75 and #7. Facility census: 55. Findings include: a) Residents #11, #34, #55, #37, #21, #75 and #7 During the initial tour of the facility, on 02/04/13, a staff member was observed passing supplements and fluids on C Hall at 11:39 a.m Employee #37, a registered nurse (RN), was passing the supplements and fluids to the residents. Employee #37 was asked if the items being passed were the 10:00 a.m. supplements and snacks. Employee #37 replied, Yes. Employee #37 then stated, The aides couldn't get to them. We're getting them out for you as fast as we can. The products included: -Resident #11, supplement -Resident #34, supplement -Resident #55, supplement -Resident #37, supplement -Resident #21, supplement -Resident #75, fluids -Resident #7, supplement At the time the supplements and extra fluid was being provided these residents, observation revealed lunch services had already begun.",2017-04-01
7571,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-02-13,364,F,0,1,HJDH11,"Based on observation, resident interview, temperature evaluations of foods, tasting of foods served, and staff interview, the facility did not ensure all foods were served in a manner that maintained palatability and/or temperature. Residents expressed concerns with taste and temperatures of foods during their confidential interviews in Stage I of the survey process. Due to this, test tray evaluations were conducted. These evaluations confirmed breakfast items were not served at appropriate temperatures, which affected palatability. This had the potential to affect all residents who consumed oral diets, as all foods were prepared and served from the dietary department. Census: 55 Findings include: a) During confidential individual interviews with residents in Stage I of the survey, on 02/04/13 and 2/05/13, three (3) residents expressed that coffee and other food items were cold at the breakfast meal. They also said food items did not taste good. b) Temperature evaluations were completed by doing test trays at breakfast on the morning of 02/12/13. Food tray carts were noted to arrive at the nursing station at 7:40 a.m The last tray was delivered from the cart with the last resident eating by 8:17 a.m. The last food trays delivered to the unit were there for 37 minutes before the last tray was served. The results indicated the temperatures were not within acceptable ranges. The hot cereal, cream of wheat, was 86 degrees Fahrenheit (F); coffee was 84 degrees F, and scrambled eggs were 80 degrees F. Foods at these temperatures would feel lukewarm, not hot, as they were below normal body temperature. This was verified with Employee #76, the executive director of the facility, who was present and assisted with evaluating the temperatures. The food items were tasted at the same time of the temperature evaluation and found to have decreased palatability due to the low temperatures.",2017-04-01
7572,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-02-13,371,F,0,1,HJDH11,"Based on observation, review of facility policy, and staff interview, it was found foods were not stored under sanitary conditions. Outdated food items were stored in the walk-in refrigerator, equipment was in soiled and/or in disrepair, and serving items such as potholders were worn to the extent they were a potential for contamination. Additionally, unlabeled and undated foods items were stored in the nursing nourishment pantry. These practices had the potential to affect all residents who were served foods from the dietary department and/or the nourishment pantry. Census: 55. Findings include: a) While conducting the initial tour of the dietary department, at 11:30 a.m. on 02/03/13, the following issues were noted: 1) The lids of containers which held flour, sugar, etc. had spills and debris on them. 2) The gasket of the walk-in freezer was torn and soiled. 3) A milk crate of outdated TruMoo chocolate milk was found in the walk-in refrigerator. Some of the individual containers had dates of 01/30/13 and 02/02/13, both of which were outdated at the time of observation. 4) Potholders the staff were using to handle hot food items were worn with the insides showing and/or protruding from holes in the coverings. 5) The handle of the upright freezer had handles which were in disrepair, creating an inability for adequate cleaning and sanitation. 6) The top of the oven was dusty and sticky to the touch. These issues were verified with Employee #52, a dietary services assistant, who was present at the time of the observations and tour. b) On 02/12/13 at 9:00 a.m., accompanied by Employee #37 (licensed practical nurse), the nourishment pantry, located near the nurses' station, was toured. The following was observed: 1) A loaf of unused bread had a date from the manufacturer of 02/07/13. 2) Several zip lock bags filled with jellies had a label for use by 02/08/13. 3) Two (2) Mighty Shakes, two (2) Magic Cups, and three (3) cartons of apple-cranberry juice had time stamps placed by the manufacturer. These stamps did not reveal a recognizable date. The facility had not placed their own date on the Mighty Shakes and Magic Cups. Three (3) cartons of apple-cranberry juice were also time stamped by the manufacturer, but this stamp did not reveal an expiration date. The facility had not placed their own date on the these items. Therefore it could not be determined when the items needed discarded. 4) Three (3) plastic bags filled with mustard and mayonnaise packages were labeled for use by 02/08/13. 5) Food items stored in a plastic bag for Resident #16 were in the refrigerator. The facility had not dated or labeled the bag to identify the content. c) A review of the facility's sanitation and food handling policy, provided by the executive director (Employee # 76) on 02/12/13 at 10:00 a.m., revealed a section entitled food labeling. This section stated: Foods must be labeled when opened with name of food and date opened and the 'use by' date. The 'use by' date (including date of preparation) must be seven (7) calendar days or less from the day the food is prepared.",2017-04-01
7573,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-02-13,372,F,0,1,HJDH11,"Based on observation and staff interview, the facility failed to ensure lids of the dumpster container were closed to ensure garbage and refuse were properly contained to prevent the harborage and feeding of vermin. This practice had the potential to affect all facility residents. Census: 55. Findings include: a) Observations of the dumpster area, on 02/04/13 at 11:45 a.m., revealed lids on the container were open. The garbage and debris were not properly secured, creating a potential to attract vermin. Employee #52, the dietary services assistant, was present and confirmed the observation.",2017-04-01
7574,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-02-13,431,E,0,1,HJDH11,"Based on observation and staff interview, the facility failed to ensure safe and secure medication storage. An unattended medication cart was observed unlocked in the hallway. This had the potential to affect more than an isolated number of residents. Facility Census: 55 Findings include: a) During the initial tour of the facility, on 02/02/13 at 11:47 a.m., a medication cart was discovered unlocked and unattended by staff on C Hallway. A Licensed Practical Nurse (LPN), Employee #20, returned to the cart after three (3) to four (4) minutes. She acknowledged she had forgotten to lock the medication cart. Five (5) residents were observed in the immediate vicinity of the cart in the hallway. Additional residents were observed moving about in other hallways.",2017-04-01
7575,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-02-13,441,D,0,1,HJDH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, it was determined a resident's catheter tubing was not properly secured in a manner to prevent the spread of infection to the resident. Catheter tubing was in direct contact with the floor under the resident's chair while the resident was ambulating in the hallway. This was evident for one (1) of five (5) residents who required the use of a catheter out of a sample of 28 in the Stage II sample. Resident identifier: #5. Census: 55 Findings include: a) Resident #5 This resident was observed, on 02/05/13 in the afternoon, ambulating in the hallway in a wheelchair near the nursing station. The resident's catheter tubing was in direct contact with the floor. Employee #36, the unit charge nurse, a licensed practical nurse, was alerted to the issue at that time. She returned the resident to her room to readjust the tubing. Medical record review found this resident was known to have chronic kidney disease and was admitted to the hospital in October 2012 with a [DIAGNOSES REDACTED]. The tubing in direct contact with the floor created an opportunity for transfer of microorganisms to the resident's urinary tract for this resident who was susceptible to urinary tract infections.",2017-04-01
7576,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-02-13,463,D,0,1,HJDH11,"Based on observation and staff interview, the facility failed to ensure all portions of the resident call system were working. Observations revealed one (1) of forty (40) residents in Stage I had a nonfunctioning call system. Resident identifier: #8. Facility census: 55. Findings include: a) Resident #8 On 02/05/13 at 9:00 a.m., an observation of the call system in Resident #8's room revealed when the resident pushed the button to engage the call light, the light did not beep into the nursing staff's pager. On 02/13/13 at 12:30 p.m., the environmental supervisor (Employee #24) verified the call system had not worked appropriately. He said he had to push the reset button on the unit to get it to work properly.",2017-04-01
7577,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-02-13,514,D,0,1,HJDH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to accurately document the provision of showers with treatments for one (1) of twenty-eight (28) sample residents. The resident's treatment administration record (TAR) revealed staff signed that the resident had showers (for treatments with [MEDICATION NAME] shampoo) on days he did not receive a shower. Resident identifier: #52. Facility census: 55. Findings include: a) Resident #52 Review of the medical record noted Resident #52 was to receive a treatment of [REDACTED]. During interviews with two (2) nursing assistants, Employee #8 and Employee #51, on 02/06/13 at 1:15 p.m., it was discovered the resident did not receive three (3) showers a week, but was provided only two (2) showers a week. Review of the resident's TAR revealed nurses signed that the resident had showers (for treatments with [MEDICATION NAME] shampoo) on days he did not receive a shower. For the months of November 2012 and December 2012, nurses documented the resident had twenty-two (22) showers he actually did not receive. Employee #75 (director of nursing) was interviewed on 02/06/13 at 2:59 p.m. She confirmed the documentation in the medical was not accurate, as it did not reflect the actual number of showers with treatments the resident was provided in November 2012 and December 2012. .",2017-04-01
7578,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-02-13,520,D,0,1,HJDH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, treatment sheet review, and care plan review, the facility failed to ensure the development and implementation of appropriate plans of action to correct identified quality deficiencies in relation to residents not receiving assistance with activities of daily living. Two (2) of twenty-eight (28) Stage II sampled residents had not received showers as ordered by their physician. The physician's orders [REDACTED]. This resulted in missed opportunities for showers and shampoo treatments. The facility had documentation revealing residents had missed several opportunities for showering, but had not identified and addressed this issue for a period of five (5) months. Resident identifiers: #34 and #52. Facility census: 55. Findings include: a) Resident #52 Observation of Resident #52, on 02/06/13 at 10:19 a.m., found the skin on this resident's face was dry, flaky and red. Review of the medical record identified this resident was ordered [MEDICATION NAME] shampoo three (3) times per week, and [MEDICATION NAME] cream to his face twice a day related to seborrheic [MEDICAL CONDITION]. The physician's orders [REDACTED]. Review of the shower schedule found this resident received two (2) showers a week, on Tuesdays and Fridays. Review of the resident's care plan found this resident had a care plan to receive [MEDICATION NAME] shampoos three (3) times a week on shower days. During interviews with two (2) nursing assistants, Employee #8 and Employee #51, on 02/06/13 at 1:15 p.m., it was discovered the resident did not receive three (3) showers a week, but was provided only two (2) showers a week. Employee #75 (director of nursing), was interviewed on 02/06/13 at 12:39 p.m. She verified the care plan did not correlate with the physician orders, and the resident was not receiving the treatment of [REDACTED]. In addition, review of the facility's treatment administration records (TAR) revealed staff signed that the resident had showers (for treatments with [MEDICATION NAME] shampoo) on days he did not receive a shower. For the months of November 2012 and December 2012, nurses documented the resident had twenty-two (22) showers he actually did not receive. Employee #75 (director of nursing) was interviewed on 02/06/13 at 2:59 p.m. She confirmed these documented showers did not accurately reflect the number of showers the resident was provided in November 2012 and December 2012. b) Resident #34 Review of the medical record for Resident #34, on 02/07/13, revealed she was scheduled for showers three (3) times each week. Records were reviewed from September 2012 through February 2013. Of the sixty-nine (69) opportunities for a shower, the records indicated thirty-one (31) times Resident #34 did not receive a shower. Review of shower documentation from the nursing assistant kiosk for Resident #34, on 02/12/13 revealed the following; -- October 2012 - nine (9) days without a shower from 10/13/12 to 10/22/12, total of seven (7) showers. -- November 2012 - fourteen (14) days without a shower from 10/29/12 to 11/12/12, total of four (4) showers. -- December 2012 - eleven (11) days without a shower from 12/20/12 to 12/31/12, total of seven (7) showers. -- January 2013 - seven (7) days without a shower from 01/01/2013 to 01/07/2013 and seven (7) days from 01/14/13 to 01/21/13, total of seven (7) showers. -- February 2013 - seven (7) days without a shower from 01/31/13 to 02/07/13, total of two (2) showers for twelve (12) days. According to the facility shower sheets, the resident did not receive a shower thirteen (13) of fifty-one (51) times the resident should have received a shower from 09/01/12 to 02/11/2013. In an interview with Employee #73 (Registered Nurse), on 02/12/13 at 12:00 p.m., showers were discussed. She stated that the showers had been an issue at one time, but the facility had worked that out. On 02/12/13 at 12:05 p.m., an interview with Employee #75 (director nursing service) confirmed there were past shower schedule issues. She checked a PRN (as necessary) schedule and could find no further evidence of received showers for Resident #34. c) On 02/13/13, at approximately 11:00 a.m., an interview about quality assurance was conducted with the director of nursing (Employee #75) and the clinical care supervisor (Employee #73). The two (2) employees said they had identified issues with residents and the showers they received. Employee #75 and Employee #73 said that in January 2013, the facility had identified the issues related to residents not receiving showers as ordered. This meant for a period of four (4) months (October, November, December, and January), the facility had not identified the issue of residents having physician's orders [REDACTED]. The director of nursing (DON) stated the facility had stopped giving resident's showers three (3) times per week in October. The director of nursing (DON) said they had planned to implement an audit tool to track residents' showers but they had not yet started the tool. The facility's quality assurance committee also had not identified the issues related to inaccurate documentation on treatment sheets, which reflected residents received showers when they had not. They had also not identified inconsistencies between physician's orders [REDACTED].",2017-04-01
7857,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2014-01-03,282,D,1,0,TR8L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident observations, the facility failed to implement a care plan related to falls for one (1) of eight (8) residents whose care plans were reviewed. Resident #31 had a care plan intervention for a tab alarm to her scoot chair at all times. During resident observations, the tab alarm was found not to be in place. Resident Identifier: #31. Facility Census: 58. Findings include: a) Resident #31 Resident #31's medical record was reviewed at 11:31 a.m. on 01/01/14. This review revealed the resident fell on [DATE], 08/18/13, 08/21/13. 08/27/13, 09/06/13, 11/05/13, and 12/05/13. The resident care plan was also reviewed. It contained the following intervention, Fall Risk: Tab Alarm with lock clip to scoot chair at all times to alert staff of patient attempts to transfer unassisted. Resident #31 was observed at 1:15 p.m. on 01/01/14. The resident was observed sitting up in her wheelchair in the hallway in front of the therapy department. She stated she was waiting to do her exercises. The resident's chair was observed and there was not a tab alarm in place. Employee #74, Quality Standard Coordinator (QSC), Registered Nurse (RN), and Employee #70, Director of Nursing (DON), RN, confirmed Resident #31's tab alarm was not in place. Employee #74 confirmed the tab alarm should have been in place in accordance with her care plan.",2017-01-01
7858,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2014-01-03,323,D,1,0,TR8L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident observations, the facility failed to provide adequate assistance devices to prevent accidents for one (1) of five (5) residents reviewed for accidents. Resident #31 had suffered multiple falls in the previous six (6) months. The facility had numerous interventions in place as a result of her falls. One (1) intervention was for a tab alarm on her wheelchair when she was up and about. During observations, the tab alarm was not found in place while the resident was up and about in her wheelchair. Resident Identifier: #31. Facility Census: 58. Findings include: a) Resident #31 Resident #31's medical record was reviewed at 11:31 a.m. on 01/01/14. This review revealed the resident fell on [DATE], 08/18/13, 08/21/13. 08/27/13, 09/06/13, 11/05/13, and 12/05/13. The resident had a physician's orders [REDACTED]. Resident #31's care plan was reviewed. It contained the following intervention, Fall Risk: Tab Alarm with lock clip to scoot chair at all times to alert staff of patient attempts to transfer unassisted. Resident #31 was observed at 1:15 p.m. on 01/01/14. The resident was observed sitting up in her wheelchair in the hallway in front of the therapy department. She stated she was waiting to do her exercises. The resident's chair was observed and there was not a tab alarm in place. Employee #74, Quality Standard Coordinator (QSC), Registered Nurse (RN), and Employee #70, Director of Nursing (DON), RN, confirmed Resident #31's tab alarm was not in place. Employee #74 reviewed the orders and confirmed the tab alarm should have been in place per her physician's orders [REDACTED].",2017-01-01
7859,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2014-01-03,514,D,1,0,TR8L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to maintain an accurate medical record for one (1) of eight (8) residents whose medical records were reviewed. Resident #31's active Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. This created the potential for the resident to receive the 30 mg dose of [MEDICATION NAME] after it was discontinued by the physician. Resident identifier: #31. Facility Census: 58. Findings Include: a) Resident #31 Resident #31's medical record was reviewed at 9:30 a.m. on 01/02/14. This review revealed the resident had a physician's orders [REDACTED]. Review of the resident's MAR found it contained the following, [MEDICATION NAME] Capsule Delayed release particles 60 mg oral once daily. The MAR, in this same section, contained the notation, take 60 mg po (by mouth) q am (every morning) and 30 mg @ (at) 5 pm. Further review of the medical record indicated the resident had been receiving, prior to 12/20/13, a 30 mg dose of [MEDICATION NAME] at 5:00 p.m.; however, this dose was discontinued on 12/20/13. Employee #73, Quality Standard Coordinator (QSC), Registered Nurse, (RN), was interviewed at 11:45 a.m. on 01/02/13. She stated she had put the orders for [MEDICATION NAME] into the computer when they were first ordered. She confirmed the resident had an order for [REDACTED].@ (at) 5 pm. She confirmed this was to help the nurses so they would know the resident was receiving two (2) separate doses of [MEDICATION NAME]. Employee #73 reported the physician did a gradual dose reduction for the [MEDICATION NAME] on 12/20/13. The 30 mg dose was discontinued. She reported whomever discontinued the medication forgot to remove the notation from the 60 mg dose of [MEDICATION NAME] on the MAR. She reported the notation was not part of the order and staff were not giving the 30 mg dose of [MEDICATION NAME]. She stated there was nowhere in the computer to document giving the 30 mg dose so staff would have known not to give the medication. Observations of the medication cart, at 12:00 p.m. on 01/02/13, revealed a medication card with four (4) doses of [MEDICATION NAME] 30 mg. The facility received 15 doses of this medication on 12/06/13. Employee #73 confirmed this medication should have been removed from the medication cart. She stated she felt staff was not giving this medication because the order was removed from the MAR indicated [REDACTED] .",2017-01-01
8156,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-09-04,309,D,1,0,752N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident observation, and resident interview, the facility failed to provide the necessary care and services to one (1) resident to enable her to maintain her highest practicable physical well-being. Resident #15 was seen by a dermatologist due to a skin condition on her back. The dermatologist ordered a medicated cream to treat the skin condition, but the facility failed to implement this order. The resident's skin condition was never treated as ordered by the dermatologist and approved by her attending physician. This was true for one (1) of five (5) sampled residents. Resident Identifier: #15. Facility Census: 59. Findings Include: a) Resident #15 Resident #15's medical record was reviewed at 3:23 p.m. on 09/02/13. This review revealed the resident was sent to a dermatology appointment on 08/12/13. The consultation report from the dermatologist was reviewed. The dermatologist noted the resident had [MEDICAL CONDITION] and dry skin to her back. The dermatologist ordered [MEDICATION NAME] 0.1 percent to the resident's back and noted a gentle cleanser should be used between medication applications, and a moisturizer should be used twice daily after application of the medicated cream. Further review revealed a nursing progress note dated 08/12/13. The note indicated the resident had returned from the dermatology appointment with a new order for [MEDICATION NAME] 0.1 percent twice daily to the resident's back, and to apply moisturizer after the medication application for four (4) weeks. This note also indicated the resident's physician at the facility approved these orders. The Medication Administration Record [REDACTED]. The review found no indication this resident ever received the medication which was ordered by the dermatologist and approved by the resident's attending physician. Employee #77, Director of Nursing (DON), was interviewed at 2:00 p.m. on 09/03/13. The DON confirmed the order was never written and the resident did not receive this medication. She felt the nurse had forgotten to write the order after he wrote the progress note. At 2:30 p.m. on 09/03/13, accompanied by the DON and Employee #78, a registered nurse (RN), Resident #15's back was observed. The resident did not appear to have a current skin condition on her back, but she did state her back itches a lot of the time.",2016-09-01
8157,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2013-09-04,514,D,1,0,752N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain an accurate and complete medical record for one (1) of five (5) sample residents. Resident #38 received a continuous tube feeding from 07/13/13 until 07/17/13 which was not documented in the resident's medical record. Resident Identifier: #38. Facility Census: 59. Findings Include: a) Resident #38 Resident #38's medical record was reviewed at 10:00 a.m. on 09/03/13. This review revealed the resident was admitted to the skilled nursing facility on 07/13/13. Resident #38 was admitted with the following physician's orders [REDACTED]. This order had a start date of 07/13/13 and discontinuation date of 07/17/13. The medication administration record (MAR) for the time period of 07/13/13 through 07/17/13 was reviewed. The resident's continuous enteral feeding for [MEDICATION NAME] 1.5 was not listed on the MAR. An interview with Employee #77, Director of Nursing (DON), conducted at 1:05 p.m. on 09/03/13, revealed the [MEDICATION NAME] had not shown on the MAR because it was a continuous feeding. She reported when the nurse put in the schedule for the feeding because it was continuous, it did not attach to the MAR. She stated enteral feedings were supposed to be documented on the MAR and this was a documentation error.",2016-09-01
9433,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2011-03-16,241,E,0,1,R8P711,"Based on observations, review of the information provided on the CMS-802, and review of medical records, the facility failed to promote care for residents in an environment that maintained or enhanced each resident's dignity. Incontinence briefs were observed lying out where anyone passing by individual residents' rooms in the hall or entering the rooms could see the briefs. This conveyed to others the residents were incontinent. Additionally, one (1) resident who required assistance with eating was not served her tray until her roommate had finished eating. Six (6) of thirty-four (34) current residents on the Stage II sample were affected. Resident identifiers: #52, #2, #9, #6, #49, and #42. Facility census: 55. Findings include: a) On Sunday, 03/06/11, between approximately 4:00 p.m. and 6:30 p.m., residents on the C-hall were observed during the initial tour of the facility and during the evening meal. Not all rooms were entered as the residents were absent. There were thirty (30) residents residing on C-hall at that time. Sixteen (16) of the thirty (30) residents were identified on the CMS-802 as being incontinent. 1. Resident #52 On 03/06/11 at 4:06 p.m., a small stack of incontinence briefs were observed on the resident's overbed table. The overbed table was against the wall next to the door to the hall way. This placed the briefs in view of anyone passing by the room. 2. Resident #2 On 03/06/11 at 6:00 p.m., two (2) incontinence briefs were observed lying on the foot of the resident's bed. The briefs were visible from the hall way. 3. Resident #9 At 6:00 p.m. on 03/06/11, two (2) incontinence briefs were observed lying on the chair by bed of Resident #9. These could be seen from the hall. This resident's most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/09/11, identified the resident as being always incontinent of bowel and bladder. She could be understood and was coded as being able to sometimes understand others. Her hearing was assessed as highly impaired. This was confirmed through interaction with the resident. When attempts were made to converse with her, she said she could not hear much. This would indicate the resident was aware of her surroundings. -- b) On the morning of 03/15/11, six (6) resident rooms were checked for incontinence briefs being out where they could be seen by others. Briefs were found in view for two (2) residents. 1. Resident #6 On 03/15/11 at 8:40 am., briefs were observed lying on a table across from the foot of the resident's bed room. This placed them in direct line of sight from the hallway. 2. Resident #49 On 03/15/11 at 8:42 a.m., an incontinence brief was observed lying on a table next to the resident's bed. -- c) Resident #42 On 03/15/11, at lunch time, dining observations were conducted. At 12:43 p.m., the tray cart was empty. Employee #70, a nursing assistant (NA), was asked whether another food cart would arrive as it was noted Resident #42 did not have a tray. The NA said she thought that was all of the trays to be served on the hall. She said she would have to get a tray for the resident, as she (the resident) did not usually eat in her room. At that time, no additional trays were observed being served to residents on the hall. Employee #70 was the only person passing trays. At 12:56 p.m., Resident #4 was observed in her room with her unfinished meal. She said she had eaten all she wanted. During this conversation, Resident #42 was served her meal - at 1:01 p.m. Although the exact time Resident #4 was served could not be determined, it was at least eighteen (18) minutes from the time Resident #4 was served until Resident #42 was served.",2015-11-01
9434,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2011-03-16,279,D,0,1,R8P711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, and resident observation, the facility failed to develop a comprehensive care plan for each resident to include measurable objectives and/or interventions to address problems identified through the comprehensive assessment and/or to achieve established goals for three (3) of thirty-four (34) residents in the Stage II sample. Resident identifiers: #17, #9, and #5. Facility census: 55. Findings include: a) Resident #17 On 03/07/11 at 10:14 a.m., an interview with Resident #17 revealed she felt her gums were shrinking and her dentures did not feel right. The resident further stated she did not know if they could make her any more dentures or not. Review of Resident #17's medical record revealed she was evaluated by a dentist on 05/06/10, 08/16/10, and 09/10/10 for improper fitting dentures and sores on her gums. On 03/10/11 at 3:30 p.m., an interview with Resident #17 revealed she had mentioned to staff about her dental problems in the past, but she had not mentioned any dental problems to staff recently. The resident further stated she had had three (3) appointments and the dentist could not fix her dentures. The resident reported she was still having discomfort, but when asked if she would like staff to be made aware and to possibly see another dentist, she stated, I don't want to fool with it anymore. The resident further stated she was able to chew, but they had to grind her meat. review of the resident's medical record revealed [REDACTED]. The evaluation further stated she did not have any chewing / swallowing problems, and her diet included ground meats, no concentrated sweets, and regular liquids. A Nursing Evaluation dated 10/21/10 revealed the resident was on a regular diet at that time. Review of Resident #17's care plan found no mention of dental problems or difficulty chewing. On 03/16/11 at 9:30 a.m., an interview with the clinical care supervisor (Employee #78) revealed she was unaware of any recent dental problems and the resident had requested she be given ground meat. She further stated she did not know why these issues were not care planned. -- b) Resident #9 1. The resident's most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/09/11, identified the resident required the extensive assistance of two (2) for bed mobility; the limited assistance of one (1) for transfers; the extensive assistance of one (1) for dressing, personal hygiene, and toilet use; and as being independent in eating with set up help only. The current care plan, noted as last reviewed on 01/13/11, had a problem identified as: (Resident's first name) has an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) poor cognition, does not complete tasks. The goal was: Patient will maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and personal Hygiene through the review date. The goal was not measurable. - The interventions were: - BED MOBILITY SELF-PERFORMANCE: Patient can turn self in bed, may need cues reminders or help through the night. - TRANSFER: herself but at times may need help, uses wheeled walker daily that has a basket on the front to carry items she uses, assure her shoes are non skid. - DRESSING: vision is poor so assist as needed to match clothes she chooses, she can dress her upper body, needs assistance with lower body. - NCS (no concentrated sweets) diet with ground meats, no salt pk (packet) on tray. - TOILET USE: Will take self to the bathroom but will need assistance, usually incontinent of urine but has bowel control, needs help to cleanse, change. - PERSONAL HYGIENE / ORAL CARE: has dentures but usually keeps them in her blouse or purse, encourage to wear, to allow oral care. - BATHING: does am (morning) care at bedside, will walk to shower, encourage to do all she can before finishing, cue, very hard of hearing so be sure she hears you. The problem statement identified she did not finish tasks, but neither the goal nor the interventions addressed this issue. - The intervention for maintaining her current ability to eat did not offer any guidance other than her diet order. At 6:00 p.m. on 03/06/11, the resident was observed to be poorly positioned in bed while trying to eat her evening meal. She had to struggle to reach her coffee sitting on the side of the tray furthest from her body. When asked if she was positioned comfortably, she said it would help to be sitting up more. The care plan did not address the need for the resident to be positioned correctly when eating. - The intervention for personal hygiene addressed encouraging her wear dentures and to allow oral care. No guidance was provided on how much assistance was needed for other aspects of personal hygiene (e.g., hair care). - 2. Another problem statement was: Problematic manner in which patient acts characterized by inappropriate hiding of snuff in blouse. The goal was: Patient will use snuff. The goal was not measurable. - The interventions were (quoted verbatim): Activities provides snuff to resident by placing it a specimen cup. mindful of resident keeps snuff in spcimen cup in her blouse or her room resident controls the powered snuff. The intent of the goal and the interventions was not clear. - 3. Another problem was: (Resident's name) has impaired visual function r/t [MEDICAL CONDITION], not to have surgery. The goal was: Patient will show no decline in visual function through the review date. The interventions were: Monitor / document / report to physician the following s/sx (signs / symptoms) of acute eye problems: Change in ability to perform ADLs. Decline in mobility, Sudden visual loss, . Ensure appropriate visual aids are available to support optimal participation in activities, large print, large pictures. The goal was stated in preventative terms, but the interventions did not offer methodologies that might be employed to prevent decline in her visual function. There was nothing related to how the resident's environment might best be adapted related to the resident's impaired vision for day to day activities. These might include optimal lighting, ways to decrease or avoid glare and methods to increase color contrast. - 4. A problem of [MEDICAL CONDITION] was identified. The goal was: Will be free from s/sx of [MEDICAL CONDITION] through the review date. The interventions were to monitor and to give her [MEDICAL CONDITION] replacement medication. No signs or symptoms were identified to offer guidance to the direct caregiver. There was no indication the resident was having any problems related to [MEDICAL CONDITION]. The goal was staff oriented, not resident oriented. - 5. The resident has risk for dehydration or potential fluid deficit r/t Diuretic use was identified as a problem. The goal was: The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. The interventions were to monitor and document intake and output and to monitor / document / report signs and symptoms of dehydration. There was no plan put into place to ensure the resident received sufficient fluids throughout the day. -- c) Resident #5 1. The copy of the care plan provided by the facility had a problem statement of: (Resident's first name) has a nutritional problem or potential nutritional problem Dysphagia. This problem statement was created on 01/25/11. The goal was: Patient will maintain adequate nutritional status as evidenced by maintaining weight within 3#, no s/sx of malnutrition, and consuming at least 75% of at least 2 meals daily through review date. The interventions were (quoted verbatim): Assist patient to preferred dining roomfeeds self with set up, occasional assistance. Serve diet as ordered Pureed, Invite patient to activities that promote additional intake. - On 03/08/11 at 8:30 a.m., the resident was observed eating. She was lying in bed on her back with her breakfast tray on an overbed table. She had slid down in the bed so her tray was above the height of her mouth. At 8:47 a.m., she had not been repositioned. At this time, she was still down in the bed and was leaning to her right. She was using her right hand to obtain the beverages on her tray, which was still above the height of her mouth. - The quarterly assessment, with an assessment reference date (ARD) of 01/23/11, identified the resident required the extensive assist of one (1) for bed mobility. - Although the problem statement identified this [AGE] year-old resident had dysphagia, the care plan did not address the need for the resident to be positioned correctly when eating. This would be of greater importance since the resident had a [DIAGNOSES REDACTED]. This may compromise nutrition and hydration and may lead to aspiration pneumonia.) - 2. The resident was admitted to the facility on [DATE]. Her care plan included a goal of: Patient will be able to continue to adjust to nursing home placement, as currently unable to prepare for discharge. This [AGE] year old resident had resided in the facility for over fourteen (14) years. She had [DIAGNOSES REDACTED]. In a discussion with the minimum data set coordinator (Employee #76), on the afternoon of 03/16/11, the resident's age, diagnoses, and admitted were pointed out in relation to the goal. She agreed the goal for adjustment to the facility was no longer appropriate. - 3. Two (2) goals were written for the problem statement of: Chronic / Progressive decline in intellectual functioning characterized by; deficit in memory, judgment, decision making and thought process related to: short term memory loss, long term memory loss. The goals were: Identify persons who routinely have contact with resident. Ability to repeat back information as understood. Neither goal was stated in measurable terms. The goal of Ability to repeat back information as understood would indicate the resident was to gain this ability. - The interventions were: Break activities into manageable subtasks. Give one instruction at a time to resident. Encourage small group activities. Establish daily routine with patient. Explain each activity / care procedure prior to beginning it. Provide cueing & prompting to ensure patient makes attempts at own care before offering assistance. Report changes in cognitive status to Unit Charge Nurse. The interventions did not offer guidance to the care giver for how the goals were to be achieved. - There were no interventions related to identifying persons who had routine contact with the resident. - There were no interventions lending to achievement of: Ability to repeat back information as understood.",2015-11-01
9435,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2011-03-16,280,D,0,1,R8P711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and resident interview, the facility failed to periodically review and revised each resident's care plan for changes in care and treatment. The facility failed to revise a care plan for Resident #45 regarding discharge planning. One (1) of thirty-four (34) residents on the Stage II sample was affected. Resident identifier: #45. Facility census: 55. Findings include: a) Resident #45 Review of Resident #45's medical record revealed the resident did not possess the capacity to understand and make her own health care decisions. On 03/10/11 at 11:30 a.m., an observation of the resident found her to be alert and ambulatory in her wheelchair. On 03/10/11 at 1:40 p.m. and 3:40 p.m., interviews with the resident revealed she was unable to answer questions asked by this surveyor regarding alleged missing clothing. Review of Resident #45's medical record revealed the following social discharge review assessments: - 11/30/10 - the discharge plan included short-term stay, the resident was planning to return home, and the resident had a support system available (e.g., resident lives with son, other sons are also involved with in home needs). Services at the time of discharge were to be determined, with the possibility that home health would be consulted depending upon the discharge orders. - 12/28/10 - the discharge plan was unknown, the resident was planning to return home, and the resident had a support system available. Discharge referrals were to be determined when / if the resident decided to return home. - 01/21/11 - the discharge plan was unknown, the resident was planning to return home, and the resident had a support system available (discharge was to be determined by the family within the next couple weeks). Discharge referrals were to be determined, and the facility stated it was possible that home health would be consulted depending upon the discharge orders. Further review of the resident's medical record revealed [REDACTED]. A progress note recorded the resident stated she had decided to stay at the facility long term. On 03/15/11 at 9:45 a.m., review of the resident's medical record revealed [REDACTED]. On 03/15/11 at 3:00 p.m., an interview with the social services supervisor (Employee #24) revealed the resident's initial discharge plan for a short-term stay with return home to live with her son, but the resident's power of attorney had requested the resident remain at the facility. The resident's power of attorney was currently applying for Medicaid and was requesting long-term placement. The resident's care plan was not revised to reflect the resident's decision, in early February 2011, to stay long-term or the resident's power of attorney's desire for the resident to remain at the facility.",2015-11-01
9436,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2011-03-16,309,D,0,1,R8P711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident comments, and medical record review, the facility failed to provide the necessary care and services to assist each resident in attaining or maintaining his or her highest practicable levels of well-being in accordance with the comprehensive assessment and plan of care. A resident, who had loss of voluntary movement in her lower legs, was observed throughout the survey to be in a wheelchair that did not provide support for her feet. Two (2) residents were observed at meal times to be positioned in poor body alignment and in a manner that did not facilitate their abilities to eat. Three (3) of thirty-four (34) Stage II residents were affected. Resident identifiers: #3, #9, and #5. Facility census: 55. Findings include: a) Resident #3 During the initial tour of the facility on 03/06/11 and throughout the survey, this [AGE] year old resident was periodically observed up in a wheelchair. Her feet did not fully touch the floor, and there were no footrests on the chair. She used her hands to wheel about the facility. The minimum data set assessment (MDS), with an assessment reference date (ARD) of 02/13/11, indicated she had loss of functional range of motion in both lower extremities. The assessment was also coded for the [DIAGNOSES REDACTED]. On 03/16/11 at 10:48 a.m., Employee #78, a registered nurse (RN) and the clinical care supervisor, was shown the resident's positioning. When asked whether a smaller wheelchair had ever been tried, she stated she did not know. Employee #87, a certified occupational therapy assistant (COTA), was in the area at that time. The lack of support for the resident's feet was pointed out to him. He looked at the wheelchair and said he could lower the chair. At 10:51 a.m., Employee #87 said the physical therapist had said a bearing needed to be fixed and her chair had been changed out last week until it could be repaired. He agreed the wheelchair she was currently using needed to be lowered a bit. -- b) Resident #9 At 6:00 p.m. on 03/06/11, this resident was observed eating her evening meal while in bed. The head of the bed was elevated, but she had slid down to the point that her mid-[MEDICATION NAME] back was in the bend of the bed. Her neck was flexed due to the pillow behind her head. The resident said it would help to be sitting up more, when asked whether she was positioned comfortably. (Due to hearing impairment, the question of whether she was comfortable had to be repeated three (3) times.) At approximately 6:10 p.m., the resident was observed reaching for her cup of coffee. She had to struggle to reach the coffee sitting on the side of the tray away from her. It was hard for her to reposition herself. The resident had to bounce off the back of the bed three (3) to four (4) times in order to reach her coffee cup. The resident's most recent MDS assessment, with an ARD of 01/09/11, identified the resident as requiring the extensive assistance of two (2) persons for bed mobility. She was coded as being independent for eating with set-up help only. -- c) Resident #5 On 03/08/11 at 8:30 a.m., this resident was observed eating while in bed. Her breakfast tray was on an overbed table. The head of her bed had been elevated to approximately 80 degrees, but she had slid down in the bed so her tray was above the height of her mouth. This also resulted in her back being flexed in the mid-[MEDICATION NAME] region. She had to reach upward to obtain her food and beverages. At 8:47 a.m., she was again observed. She had not been repositioned. At that time, she was also leaning to her right, as well as having slid down in the bed. She was using her right hand to obtain the beverages from her tray. This position required an increase in the amount of effort exerted to obtain items from the tray. - The quarterly assessment, with an ARD of 01/23/11, indicated the resident required the extensive assist of one (1) person for bed mobility, transfer, and eating. This [AGE] year old resident's [DIAGNOSES REDACTED]. Review of the copy of the care plan provided by the facility revealed a problem of: (Resident's first name) has a nutritional problem or potential nutritional problem Dysphagia created on 01/25/11. The goal associated with this problem statement was: Patient will maintain adequate nutritional status as evidenced by maintaining weight within 3#, no s/sx (signs / symptoms) of malnutrition, and consuming at least 75% of at least 2 meals daily through review date. The interventions were: Assist patient to preferred dining roomfeeds (sic) self with set up, occasional assistance. Serve diet as ordered Pureed, Invite patient to activities that promote additional intake. The care plan did not address positioning during meal times. - On 03/15/11 at 8:30 a.m., the resident's breakfast was untouched. The flatware on her tray was still wrapped in a napkin. The resident was asleep with the head of her bed at approximately 80 degrees. She was not sitting upright despite the head of the bed being elevated. At 8:35 a.m., the resident's tray removed. A staff member was observed entering the resident's room. Less than a minute passed from the time the staff member entered the room until she exited with the resident's tray. Had the resident been awake, she would not have been in a position where she could have comfortably reached her food. - On 03/15/11, at lunch time, Employee #70, a nursing assistant (NA) served the resident her lunch while she was in bed. The resident had her knees flexed and the NA attempted to straighten the resident's legs so she could position the overbed table. When the NA tried to straighten the resident's legs, she pulled on the resident's lower legs. This resulted in the resident sliding down in bed and not being positioned to facilitate ease of eating. The resident was heard coughing at one time during lunch but was able to clear her throat without staff intervention.",2015-11-01
9437,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2011-03-16,323,G,0,1,R8P711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on family interview, medical record review, and staff interview, the facility failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents with injuries for one (1) of thirty-four (34) Stage II sample residents. Record review revealed Resident #48 fell from her bed on the morning of 01/31/11 and sustained a compression fracture of the T-4 vertebra and a facial bone fracture. Further review of the record revealed she had sustained two (2) previous falls from her bed (on 08/23/10 and 11/07/10) with no injuries; however, the interdisciplinary team did not revise the resident's care plan after these falls to include interventions that would serve to either prevent the resident from falling out of bed and/or reduce the likelihood of serious injury from such a fall. The care plan interventions for falls remained essentially unchanged since 08/30/10, with a reliance on the use of bed and chair alarms to alert staff to unassisted self-transfers. The use of bed bolsters and floor mats was not added to her overall plan of care until after the 01/31/11 fall. Resident identifier: #48. Facility census: 55. Findings include: a) Resident #48 1. When interviewed on 03/07/11 at approximately 2:00 p.m., Resident #48's daughter stated she did not understand why the facility had not initiated the use of more safety devices (such as fall mats in her mother's room) after Resident #48 fell in November 2010. The resident had subsequently sustained a fall with injuries in January 2011. -- 2. Record review revealed Resident #48 was an [AGE] year old female originally admitted to the facility on [DATE], with her most recent admission occurring on 06/29/10. According to her most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 02/06/11, Resident #48 scored 4 on the Brief Interview for Mental Status (BIMS); a resident scoring between 0 and 7 is considered to have severe cognitive impairment. In Section C1300 (Signs and Symptoms of Delirium), the assessor noted the resident exhibited inattention (2 - Behavior present, fluctuates). In Section C1600 (Acute Onset Mental Status Change), the assessor noted there was no evidence of an acute change in mental status from the resident's baseline. In Section G (Functional Status), the assessor noted the resident required the extensive physical assistance of two (2) or more persons for bed mobility, transfer, and toilet use. In Section G0300 (Balance During Transitions and Walking), the assessor coded 2 for moving from a seated to a standing position, moving on and off the toilet, and making surface-to-surface transfers (transfer between bed and chair or wheelchair), with 2 meaning the resident was Not steady, only able to stabilize with human assistance. In Section G0400 (Functional Limitation in Range of Motion), the assessor noted the resident had impairments in range of motion of upper and lower extremities on both sides. In Section I (Active Diagnoses), the assessor noted the following [DIAGNOSES REDACTED]., dementia other than Alzheimer's disease, Parkinson's disease, seizure disorder, anxiety, depression, and a psychotic disorder other than schizophrenia. Additional [DIAGNOSES REDACTED]. In Section J1800, the assessor noted the resident had experienced falls since admission or since the prior assessment. In Section 1900, the assessor noted the resident had one (1) fall with a major injury. -- 3. Review of the resident's current care plan (last reviewed by the facility on 02/15/11) found the following problem statements (quoted below as recorded in the record): - ADL (activities of daily living) performance requires extensive assist, Parkinsons, tremors. The goal was: Patient will maintain adequate level of function. Interventions included: Fall Risk. (These were all dated as having been initiated on 09/13/10.) - (PATIENT has experienced an actual fall with compression fx (fracture), injury to her face 01/31/2011 risk for further fall/injury. The goal was: Patient will resume usual activities without further complication through the review date. The interventions were: RISK OF INJURY FROM FALL:alarms to bed and w/c (wheelchair) to alert staff she needs assistancebed in lowest position when in bed bed bolsters on bed, falls matts by the bed non skid cushion in w/c. Continue interventions on the at-risk plan. Monitor / document / report to physician for s/sx (signs / symptoms): Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. HIGH FALL RISK: Anticipate and meet patient's needs. (The last intervention was noted to have been initiated on 01/06/11, while the problem statement, goal, and other interventions were noted to have been initiated on 11/09/10, even though the fall with injury occurred after this date on 01/31/11. Please also note no at-risk plan was found elsewhere in the comprehensive care plan.) -- 4. Review of the resident's nursing notes revealed the resident sustained [REDACTED]. A nursing note, dated 01/31/11 at 10:10 a.m. (quoted verbatim), stated:. Alerted to resident's room resident lying on floor on stomach looking towards bed. Blood noted on floor from resident's face. Bleeding controlled, Resident remained on stomach not moved. 911 phoned, Daughter notified. A subsequent nursing note, dated 02/01/11 at 1:01 a.m. (quoted verbatim), stated: . resident has returned from (name hospital) with facial fracture .alert talking re: (regarding) her fall today able to move all extremities .noted bil. (bilateral) bruising to eyes and across nose also swelling . bed alarm on call light given to pt. inst (instructed) not to get oob (out of bed) call for help bed down to low position. A nursing note, dated 02/03/11 at 8:00 a.m., stated: . Follow up to fall . Floor mats and bed bolsters ordered. A nursing note, dated 02/04/11 at 12:41 a.m. (quoted verbatim), stated:. follow up to fall. Has weak grips but that is normal for this resident. Bruising noted to nose and eyes. Bed in lowest position, bed alarm remains on and falls mat to side of bed. A nursing note, dated 02/05/11 at 5:14 p.m. (quoted verbatim), stated: . Nursing Assessment: Eyes are black, broken nose, T-4 fracture. Review of the resident's physician orders [REDACTED]. The order stated: Bed Bolsters while in bed for positioning and to facilitate a tactile barrier to provide a sense of bed boundaries. -- 5. According to her nursing notes, Resident #48 previously sustained a fall from her bed on the early morning of 11/07/10: Resident found sitting on bottom in the floor beside floor. Resident stated 'I want to use the commode.' 'I'm not hurt.' A nursing note, dated 11/08/10 at 4:10 a.m. (quoted verbatim), stated:. Resident fall on 11/07/10 2300-700 (11:00 p.m. to 7:00 a.m. shift). Resident resting with eyes closed. No acute distress not=ed (sic) . No complaints voiced. No grimacing noted. Communication of concern or assessment to physician: None at this time. Physician Response or Order given: None at this time. Physician Response or Order given: None at this time. Communication of physician's response or order: None at this time. Patient / Health Care Decision Maker Notification: None needed at this time. A subsequent nursing note, dated 11/09/10 at 4:01 a.m. (quoted verbatim) stated: . Previous fall. Resident resting quietly at present, with eyes closed. Bed in decreased position with call light within reach. 0 s/s of distress observed. 0 pain verbalized thus far this shift. Continue to observe. Bed alarm present and active. CNA monitoring q1hr (every hour). Redirection to use call bell when needing assistance and ambulation for any reason. -- 6. Review of her previous MDS, a comprehensive assessment for a significant change in status, with an ARD of 11/14/10, revealed the BIMS was not completed, as the resident, at that time, was rarely / never understood. In Section C0700, the assessor noted the resident had problems with both short and long-term memory, she was oriented to person only, and her cognitive skills for daily decision-making were moderately impaired. In Section C1300, the assessor noted she exhibited inattention and disorganized thinking (both encoded 2, meaning Behavior present, fluctuates). The assessor also noted, in Section C1600, that this represented in acute change in her mental status from the resident's baseline. In Section G, the assessor noted the resident required the extensive physical assistance of one (1) person for bed mobility and two (2) or more persons for transfers and toilet use. In Section G0300, testing for balance could not be completed, and in Section G0400, the assessor noted the resident had impairments in range of motion of upper and lower extremities on both sides. In Section I, in addition to the previously stated diagnoses, the assessor also noted the resident's current functional status was affected by the following Diagnoses: [REDACTED]. In Section J1800, the assessor noted the resident had experienced falls since admission, and in Section J1900, the assessor noted the resident had one (1) fall with no injury. In Section V0200, the assessor indicated that falls would be addressed on the resident's care plan. -- 7. Review of the care plan that had been reviewed / revised after the 11/14/10 MDS (and after the 11/07/10 fall) revealed the following (quoted below as recorded in the record) the following problem statements: - ADL (activities of daily living) performance requires extensive assist, Parkinsons, tremors. The goal was: Patient will maintain adequate level of function. Interventions included: Fall Risk. (These were all dated as having been initiated on 09/13/10.) - (PATIENT has experienced an actual fall with no injury noted at the time. The goal was: Patient will resume usual activities without further complication through the review date. The interventions were: RISK OF INJURY FROM FALL:alarms to bed and w/c staff she needs assistance. Continue interventions on the at-risk plan. Monitor / document / report PRN (as needed) x 72h (72 hours) to physician for s/sx: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. (These were all dated as having been initiated on 11/09/10. No at-risk plan was found elsewhere in the comprehensive care plan.) -- 8. Further review of the resident's medical record revealed [REDACTED]. A nursing note, dated 08/23/10 at 2:30 a.m. (quoted verbatim), stated, Residents bed alarm sounded - two CNA's (nurse aides) and a nurse went to check on resident. Resident found on (R) (right) side of bed in floor, head was under chair and (L) (left) arm was under residents back. Resident states she doesn't recall what happened or how she fell in floor. (R) side of cheek is reddened and (L) elbow has small bruise on it. Moves all extremities freely. Residents POA (power of attorney) notified - (name of daughter) @ 225 AM (2:25 a.m.). Dr. (name) notified @ 215 A (2:15 a.m.) Will cont (continue) to monitor . The next consecutive nursing note, dated 08/23/10 at 4:45 a.m., stated: Resident resting /c (with) eyes closed. Has attempted to get up /c out assistance - redirected resident to use call bell when wanting to get out of bed for any reason . -- 9. Review of the care plan developed after the fall on 08/23/10 revealed the following problem statement (which was created on 08/30/10): Has fallen with risk of further falls due to weakness, confusion, transfers without help. The goal was: Resident will be free from falls with fx (fracture) or injury requiring a hospital visit through this review. The interventions were: Transfer with 1 assist to w/c with no skid matt. Therapy to work with resident for safety, transfers, mobility and ambulation as well as simple grooming. nursing monitor for any med (medication) changes for cognitive changes, dizziness, lethargy. bed alarm and chair alarm to alert staff assistance is needed. The following intervention was handwritten on the care plan after it had been printed, although the entry was not dated: Special pressure sensitive call light / nursing. -- 10. Resident #48 participated in physical therapy in the summer of 2010. According to Employee #88 (physical therapist), the resident's original goal consisted of rehabilitation and then returning home. However, she had declined, and the goal changed. The physical therapist said the therapy department had Resident #48 on their case load in the summer of 2010 but stopped working with her around September 2010. She had made progress and walked some with a walker at that time. However, that progress did not last as she declined after discharge from therapy. After September 2010, Resident #48 received speech and occupational therapy to work on positioning in her wheelchair and on positioning during meal time. The physical therapist said her department did not screen the resident following the 11/07/10 fall, because she was not currently on their case load at that time. -- 11. On 03/09/11 at approximately 1:00 p.m., the clinical care supervisor (Employee #78) reviewed the resident's medical record and stated she was not sure why the facility had not ordered floor mats for the resident after the 11/07/10 fall from bed. She stated she thought the family had said they did not want the mats, because they were afraid they would trip over them while visiting with her. However, no documentation of this statement attributed to the family was located in the resident's medical record or on the facility's 24-hour daily report. -- 12. Resident #48's active [DIAGNOSES REDACTED]. She required extensive physical assistance from staff with her activities of daily living due to the tremors associated with her Parkinson's disease. She had periods of confusion and disorientation and chronic pain. When she sustained a fall from bed without an injury on 08/23/10, her care plan was revised to include treatment by therapy staff to address safety, transfers, mobility, and ambulation. Her care plan also referenced the use of bed and chair alarms and the provision of a pressure sensitive call light. Resident #48 sustained a second fall from her bed on 11/07/10. In the months prior to this fall, the resident had been discharged from physical therapy. After the fall occurred, no interventions were added to her care plan that would prevent falls from bed and/or reduce the likelihood of injuries from such falls. On 01/31/11, Resident #48 sustained the third fall from her bed, which resulted in fractures of her T-4 vertebra and facial bones. After this third fall, which resulted in major injuries, the facility implemented the use of bed bolsters and floor mats. The resident has not fallen from bed since the bed bolsters were initiated. -- Part II -- Based on observation and staff interview , the facility failed to provide a resident environment as free as possible of accident hazards. Unlocked storage cabinets located in common bathing areas contained hazardous materials, including razors, medications, and hygiene supplies labeled for external use only. The unrestricted access of these items posed the potential for more than minimal harm to more than an isolated number of residents (especially residents who were independent in locomotion with impaired cognition). Facility census: 55. Findings include: a) Resident central shower areas 1. During the initial tour of the facility on 03/06/11, the following potentially hazardous items were observed in the common shower areas on C-hall: a. In the women's shower area in an unlocked cabinet (the cabinet was equipped with a lock): - A bottle of Nystop (Nystatin) powder labeled for external use only. The medicated powder was a prescription item and had a pharmacy label indicating it was for Resident #36. - Two (2) boxes of ten (10) Dawn Mist Disposable 3 Blade Razors. - Bottles of Selsun blue shampoo and Rugby anti-dandruff shampoo which bore manufacturers' labels for external use only. - b. Among the many things stored in the Century tub, located between the men's and women's central shower areas, were two (2) bottles of Rugby anti-dandruff shampoo (blue formula) labeled for external use only. - c. In the men's shower area in an unlocked cabinet (the cabinet was equipped with a lock): - Three (2) boxes of razors, Selsun Blue shampoo, and one (1) ounce bottles of after shave. - A bottle of Ammonium Lactate 12% with a prescription label for Resident #6. The bottle was labeled for external use only. -- 2. On 03/09/11 at 1:15 p.m., the shower areas were again checked accompanied by the life safety surveyor and Employee #84 (the facility's environmental coordinator). The cabinets were again found unlocked. The bottle of Nystop (Nystatin) powder was still in the cabinet. Employee #84 agreed the medication should not be in the shower room. She took the bottle to the director of nursing's office immediately. By virtue of the medicated powder being in a common area in an unlocked cabinet, it could be accessed by ambulatory residents, could be applied to someone for which it was not ordered, and did not meet the requirements for storage of medications. (See also citation at F431.) The other items, previously noted on 03/06/11, were also still found in the cabinets, with the exception of the Ammonium Lactate for Resident #6. -- 3. On 03/15/11 at 12:27 p.m., the shower rooms were again checked. The non-prescription items found on previous visits remained in unlocked cabinets. On this occasion, a bottle of Nizoral Shampoo labeled for external use only and bearing a prescription label for Resident #62 was also found. -- 4. On 03/15/11, at 12:50 p.m., the administrator was informed of these findings. She locked the cabinets at that time.",2015-11-01
9438,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2011-03-16,353,C,0,1,R8P711,"Based on staffing schedule review, staff interview, and review of facility policy, the facility failed to designate a licensed nurse to serve as a charge nurse on each tour of duty. The facility was unable to identify a designated charge nurse. This practice has the potential to affect all residents. Facility census: 55. Findings include: a) Review of the facility's nursing schedule for 03/01/11 through 03/31/11 no charge nurse was designated on the schedule. Review of the facility policy titled Unit Charge Nurse Designation revealed the A Hall unit charge nurse on all shifts shall be designated as in charge of the facility at all times. On 03/14/10, an interview with the clinical care supervisor (Employee #78) revealed it was understood by staff that, on evenings and weekends, the nurse on A, B, & D Halls was the charge nurse, and during day shift, each unit nurse manager was in charge of their unit. She further confirmed this was not designated on the schedule.",2015-11-01
9439,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2011-03-16,428,D,0,1,R8P711,"Based on record review and staff interview, the facility failed to ensure the consultant pharmacist conducted a medication regimen review at least monthly for two (2) of thirty-four (34) Stage II sample residents. Resident identifiers: #48 and #12. Facility census: 55. Findings include: a) Residents #48 and #12 Record review, on 03/15/11 at approximately 2:00 p.m., revealed the consultant pharmacist failed to review the medication regimens of two (2) residents (#12 and #48) on a monthly basis. The pharmacist reviewed these residents' medication regimens on 10/29/10, but a review was not completed again until 12/03/10. Employee #83 (vice president of compliance) contacted the pharmacist, and he reported he had a 7-day grace period after the thirty (30) day period was over in order to complete monthly medication regimen reviews. This information was not consistent with the federal guidelines, which state a medication regimen review must be conducted at least monthly. The federal guidance does not allow for a grace period.",2015-11-01
9440,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2011-03-16,431,E,0,1,R8P711,"Based on observation and staff interview, the facility failed to store all drugs and biologicals in locked compartments under proper temperature control, and labeled in accordance with currently accepted professional practice and with the date opened, when applicable. The facility failed to maintain a temperature log for the refrigerator in the medication storage room. The facility failed to properly label and dated medications stored in the refrigerator in the medication room. The facility also failed to store medications in a locked compartment in a common area. These practice have the potential to affect more than an isolated number of residents. Facility census: 55. Findings include: a) Observation, on 03/09/11 at 11:25 a.m., found no temperature log for the refrigerator in the medication storage room. On 03/09/11 at 11:25 a.m., an interview with the director of nursing (DON - Employee #79) revealed she was going to contact the midnight shift nurse in an attempt to locate the temperature log for the refrigerator in the medication storage room. On 03/10/11 at 3:30 p.m., the DON reported they could not locate a temperature log for this refrigerator and a new temperature log was started on 03/09/11. -- b) On 03/10/11 at 1:50 p.m., two (2) open vials of Tuberculin, purified protein derivative, diluted Aplisol were found not dated, and a vial of Novolin R was found with no label or date. On 03/10/11 at 1:50 p.m., an interview with the clinical care supervisor (Employee #78) confirmed these medications should have been properly labeled and dated when opened. -- c) Residents #36, #6, and #62 Medicated items, labeled with pharmacy labels for individual residents, were found in unlocked cabinets in the common shower areas for these three (3) residents as follows: - Resident #36 - A bottle of Nystop was found in the cabinet on 03/06/11 and 03/09/11. - Resident #36 - A bottle of Ammonium Lactate 12% was found on 03/06/11. - Resident #62 - A bottle of Nizoral shampoo was found on 03/15/11. These items were not stored in a locked cabinet or area and were accessible to unauthorized staff and residents.",2015-11-01
9441,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2011-03-16,441,E,0,1,R8P711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interviews, review of facility policy, and review of information regarding Clostridium difficile (C. diff) in an Infection Control Today article and from the Centers for Disease Control (CDC), the facility's infection control program failed to ensure staff used practices to prevent the development and / or spread of infection. A staff member used alcohol-based hand rub instead of hand washing with soap and water after exiting a room where a resident was on isolation precautions due to a [DIAGNOSES REDACTED] infection. A resident, who had a history of [REDACTED]. She wiped both eyes several times with the napkin she had used at breakfast and to wipe her nose. A nurse who was present at the time did not intervene. Personal use items, such as a hair brush, roll on deodorant, and so on, were stored in the common shower areas without being labeled for the name of the resident for which they were to be used. Open beverage containers were found stored with the personal hygiene items. A stuff animal was lying in the bottom of the Century tub. These practices had the potential to affect more than an isolated number of residents. Resident identifiers: #51, #13, and any resident for which the practices described in these finding affected. Facility census: 55. Findings include: a) Resident #51 On 03/16/11 at 7:55 a.m., Employee #72, a nursing assistant (NA), delivered a meal tray to Resident #51, who was in isolation for [DIAGNOSES REDACTED]. The NA exited the room, without having washed her hands with soap and water, and went to serve another resident his tray. At 7:59 a.m., the NA was asked whether she had washed her hands when exiting Resident #51's room. She said she had used her hand sanitizer and pulled the bottle out of her pocket. As alcohol-based hand rubs are not effective against [DIAGNOSES REDACTED], the outside of the employee's hand sanitizer bottle was potentially contaminated. By replacing it in her pocket, her pocket was also potentially contaminated. This provided an opportunity for transmission of infection to other residents. A copy of the facility's policy and procedure regarding [DIAGNOSES REDACTED] was obtained. It included: . Use of soap and water, rather than alcohol based handrubs, for mechanical removal of spores from hands, . Prevalence and Prevention from the periodical titled Infection Control Today, in an article dated 01/29/2009, included: While the introduction of alcohol-based hand rubs has improved hygiene practices in many hospitals, these cannot help in the case of [DIAGNOSES REDACTED], where handwashing must be done with soap and water. Since the bacteria's spores can survive the alcohol disinfectant, healthcare workers who may have been exposed to [DIAGNOSES REDACTED] must was their hands with soap and water for at least 15 seconds to prevent the spread of this bug. Frequently Asked Questions about Clostridium difficile for Healthcare Providers from the CDC included: Because alcohol does not kill Clostridium difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs. -- b) Resident #13 On 03/08/11 at 8:37 a.m., Employee #21, a registered nurse (RN), was observed administering medications to this resident. The nurse offered the resident her [MEDICATION NAME] eye drops (for elevated intraocular pressure), but the resident declined. The resident began to talk about her eyes. She said sometimes there is pus that covers her eye and she gets infections in them. During this time, she took a napkin, which was lying over an uneaten hard boiled egg and scraps of toast, and used the napkin to wipe her nose prior to [MEDICATION NAME] being administered nasally. As she continued to talked about her eyes, she used the same napkin to wipe her eyes repeatedly, going back and forth from one (1) eye to the other. The RN did not encourage the resident to get a clean tissue from the box sitting on the overbed table - within easy reach. Review of the resident's nursing notes found the resident had received antibiotic eye drops ([MEDICATION NAME]) the latter part of December 2010 until 01/05/11 for conjunctivitis. -- c) Common shower areas and the handicapped bathroom On 03/06/11, during the initial tour of the facility, the following were observed: - There were three (3) plastic containers for bedside commodes (BSC) observed sitting on the floor under the sink in the handicapped bathroom. The containers were stacked with one inside the other. A brown substance could be seen smeared on the container on top of the stack. The covers for the container were also sitting directly on the floor next to the containers. - A number of miscellaneous items were stored in the Century tub. These items included: + A nearly empty bottle of Sprite + A purple and green stuffed animal lying in the bottom of the tub + A clip board + Evoke roll-on deodorant not labeled for any specific resident + A hairbrush with a yellow handle and black bristles not labeled for any specific resident + A variety of shampoo bottles + Two (2) boxes of gloves + A hair dryer + A 4 liter dispenser of [MEDICATION NAME] - An insulated mauve mug (approximately 1 quart) with a straw and approximately two (2) inches of water in it was in a cabinet on the men's side of the shower rooms. The mug was not covered. -- d) On 03/15/11, an open can of Pepsi was observed in the cabinet on women's side of the shower area. The can was not covered. An uncovered insulated mug with a straw remained in the cabinet. On this day, there was more water in the mug than there had been when observed on 03/06/11. -- e) Throughout the survey, periodic observations of the handicapped bathroom found the containers for bedside commodes sitting on the floor under the sink.",2015-11-01
10184,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2012-02-09,309,D,1,0,YWNE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of the quality control log, interview with hospice staff, and staff interview, the facility failed to provide care and services to ensure the highest possible level of well-being for one (1) of six (6) sampled residents. The resident was not provided a medication ordered for breathing, and hospice was not notified when the resident's health status required a transfer to the hospital. Resident identifier: #57. Facility census: 56. Findings include: a) Resident #57 1) Medical record review found Resident #57 was an [AGE] year old male with [DIAGNOSES REDACTED]. He was enrolled in the hospice program for end-stage [MEDICAL CONDITION]. Further medical record review revealed the physician saw the resident on [DATE]. At that time, the physician ordered an anti-[MEDICAL CONDITION] steroid, [MEDICATION NAME] 40 (forty) milligrams, in gradually tapering doses, to help the resident's breathing. Review of the Medication Administration Record [REDACTED]. Review of the nurse's notes and the MAR indicated [REDACTED]. On [DATE] in the late afternoon, Employee #56 said she had given the [MEDICATION NAME] on [DATE] to Resident #57. The nurse said she had taken the medication from the emergency medication box. Review of the Quality Control Log found no evidence any [MEDICATION NAME] had been removed from the emergency medication box on [DATE]. During an interview with the director of nursing (DON), on [DATE] at 4:00 p.m., she said the order for [MEDICATION NAME] was entered into the computer at 6:50 p.m. on [DATE]. When asked when she would expect the new order for [MEDICATION NAME] be administered, she said she would expect the nurse to start the medication at least by the next medication pass, which in this case would have been at 9:00 p.m. The DON said she did not know of any policy regarding when to begin new orders. She agreed there was no record the [MEDICATION NAME] was removed from the emergency box on [DATE], and no evidence the [MEDICATION NAME] was administered on [DATE]. 2) Review of facility documentation revealed Resident #57 was transferred to the hospital, at approximately 11:30 p.m., on [DATE]. Nurse's progress notes, dated [DATE], contained no documentation of events leading up to his transfer to the hospital on [DATE]. Review of the nurse's progress notes also found no documentation that hospice was notified of the transfer. During an interview with hospice nurse #1, on [DATE] at 3:55 p.m., she stated hospice was not notified of the resident's transfer to the hospital. The nurse stated she found out the resident was in the hospital when the resident called the hospice office, on [DATE] around 4:30 p.m., to let them know he was hospitalized . He asked hospice to pick up his glasses and his list of important phone numbers from the nursing home. The hospice nurse said she saw the resident the morning of [DATE] at the hospital, and he was unresponsive. Resident #56 died later that night. In an interview, on [DATE] at 4:00 p.m., the director of nursing said there was no policy about when to notify hospice. She said if there was a decline, hospice would be notified. During an interview with the clinical care coordinator of the hospice program, on [DATE], she said she expected notification from the facility of any changes in the plan of care. She elaborated that being sent out to the hospital is a change in the plan of care. During an interview with the administrator and a facility corporate employee on [DATE] at 9:30 a.m., these concerns were discussed. No further information was provided. .",2015-06-01
10185,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2012-02-09,425,D,1,0,YWNE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, review of controlled substance records, the emergency medication inventory list, and policy review, the facility failed to ensure pharmacy services, related to the acquisition of medications and the destruction of controlled medications, were implemented as required by this regulation and/or according to facility policy. Facility nurses failed to witness the wasting of controlled medications, by more than one (1) nurse, when anti-anxiety medication was wasted for one (1) of six (6) sampled residents. Additionally, the emergency medication box contained no oral Prednisone. According to the emergency box contents list, there should have been twenty (20) tablets. The quality control log found no information as to when the Prednisone had been obtained, for whom it had been prescribed, or when it was removed from the emergency box by licensed nursing staff. Resident identifier: #56. Facility census: 56. Findings include: a) Resident #56 Resident #56 was a [AGE] year old with [DIAGNOSES REDACTED]. Review of the medical record found she was prescribed a controlled anti-anxiety medication, Ativan, every night at bedtime. Review of the individual resident's controlled substance record found Resident #56 refused Ativan at bedtime thirteen (13) times as follows: 12/31/11, 01/02/12, 01/03/12, 01/04/12, 01/06/12, 01/07/12, 01/08/12, 01/09/12, 01/13/12, 01/15/12, 01/19/12, 01/20/12, and 01/21/12. These refused controlled medications had to be wasted (destroyed). Only one (1) nurse signed off as a witness to the wasting of the medications. The director of nursing (DON) produced a policy related to controlled medication use, at 11:00 p.m. on 02/06/12. In part, the policy addressed that a nurse who wasted a controlled medication was required to sign and date the declining inventory sheet in the appropriate location. Also, the ""waste must be witnessed, co-signed, and dated by another nurse on the declining inventory sheet."" There was no second nurse's signature as a witness to the wasting of the Ativan on the dates listed above. During an interview with the DON, on 02/06/12 at 11:00 p.m., she confirmed two (2) nurses were supposed to sign their names verifying the witness of the medication when it was wasted. She stated she was aware that some controlled medications were wasted without two (2) nurses signing as witnesses to the wasting. The DON stated she gave a staff in-service on 01/16/12 to address this problem. When shown the Ativan was wasted without two (2) witnesses after the date of the staff training, notably on 01/19/12, 01/20/12, and 01/21/12, the DON said she was not aware this had occurred. During interview with the administrator and corporate consultant, on 02/09/12 at 9:30 a.m., these findings were discussed. The facility provided no further information regarding the findings. b) Review of the emergency medication inventory list, at 4:30 p.m. on 02/08/12, found the emergency box was supposed to be stocked with 20 (twenty) oral Prednisone tablets, an anti-inflammatory drug often used to treat respiratory problems or allergic conditions. Observation of the emergency box contents, at 4:40 p.m. on 02/08/12, found it contained no Prednisone. During an interview with the DON at this time, she said nurses were supposed to fax the pharmacy with the name of the drug and dosage, and to whom the medication was administered. This was to ensure the pharmacy would know the stock required replenishing. The DON provided a policy related to the emergency drug kit. It stated the nurse was supposed to enter a full record of the drug withdrawn from the emergency drug kit on the ""Emergency Drug Usage Form."" This form was kept in the emergency drug kit. The completed form was to be faxed to the pharmacy, so a replacement could be delivered to the facility. When asked, the DON said there was no ""count sheet"" on non-narcotic medications, to monitor the number of each medication remaining in the emergency drug box at any given time. Their system was to fax the pharmacy with the name of the medication and the amount removed each time a medication was removed from the emergency drug box. This was how the pharmacy knew to replenish the stock in the emergency drug kit. The DON confirmed Prednisone should have been stocked in the emergency drug box, yet was not. During interview with the administrator and corporate consultant, on 02/09/12 at 9:30 a.m., these findings were discussed. The facility provided no further information regarding the findings. .",2015-06-01
10186,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2012-02-09,514,E,1,0,YWNE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, review of the shift count verification sheets for controlled substances, and staff interview, the facility failed to maintain accurate documentation, on the change of shift narcotic count sheets, in the clinical records for three (3) of six (six) sampled residents. Additionally, the facility failed to transcribe physician's orders [REDACTED]. Resident identifiers: #57, #58, and #17. Facility census: 56. Findings include: a) Resident #57 Medical record review revealed Resident #57 was transferred to the hospital late in the evening on 01/16/12. Review of the facility's notification of transfer/discharge form found it did not contain the time of the transfer out of the facility. Review of nurse's progress notes found there was no documentation indicating when the resident was transferred to the hospital, or the events leading up to the transfer. Review of the medical record found Resident #57 was seen by the physician on 01/16/12. At that time, new orders were written, but the time of the new orders was not written on the physician's orders [REDACTED]. and/or new orders in the plan of care. Interview with the director of nursing (DON), on 02/07/12 at 5:55 p.m., revealed Resident #57 asked to see the physician the morning of 01/16/12. He was put on the acute care list and was seen by the physician early that afternoon. The DON said later in the evening the resident asked to go to the hospital, so he was transferred at his request. The DON confirmed there was no time of transfer in the nurse's notes or on the discharge/transfer form. Medical record review revealed the physician ordered [MEDICATION NAME] four (4) ten (10) milligram tablets for a total of 40 milligrams to be given for a total of three (3) days, then decreased gradually. This was ordered on 01/16/12. Review of the Medication Administration Record [REDACTED]. for the first three (3) days. Also, it was incorrectly entered, on the MAR, to begin on 01/17/12, and not on 01/16/12 as ordered. There was no time recorded, on the physician's orders [REDACTED]. b) Resident #58 Medical record review revealed a physician's orders [REDACTED]. Review of the MAR for January 2012 revealed the order ""Verify [MEDICATION NAME] placement x 2 (two) nurses q (every) shift at shift change"" three (3) times per day."" Review of the [MEDICATION NAME] placement check for January 2012 revealed the absence of either the on-coming or off-going nurse's signature at the change of shift a total of 35 (thirty-five) times from 01/04/12 through 01/27/12. c) Resident #17 Medical record review revealed a physician's orders [REDACTED]. Review of the [MEDICATION NAME] placement check for January 2012 revealed the absence of either the on-coming or off-going nurse's signature at the change of shift a total of 46 (forty-six) times from 01/04/12 through 02/06/12 at 3:00 p.m. During an interview with the DON, on 02/06/12 at 11:00 p.m., she said they ""let the ball drop on that one."" d) Medication carts The shift count verification sheet for controlled substances was observed on 02/06/12 at 11:00 p.m. The sheet had spaces for signatures of the on-coming nurse and the off-going nurse for all three (3) shifts. At this time, interviews were conducted with two (2) nurses, Employees #14 and Employee #51. This interview revealed the on-coming and off-going nurses, on each shift, were supposed to count the narcotics, then sign their names attesting the count was completed and correct. Review of the C Hall medication cart, on 02/06/12 at 11:00 p.m., revealed blank spaces rather than signatures for either the beginning or ending shifts a total of thirty-nine (39) times between 12/12/11 and 02/06/12. Review of the A, B, and D Hall medication cart, on 02/06/12 at 11:00 p.m., revealed blank spaces rather than signatures for either the beginning or ending shifts a total of fifty-one (51) times between 12/19/11 and 02/06/12. These findings were reported to the DON, on 02/06/12 at 11:00 p.m., with no further information obtained. .",2015-06-01
10915,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2011-07-27,441,F,1,0,E44N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, review of employee time records, and review of employee work releases, the facility failed to establish and maintain an infection control program to assure the prevention, to the extent possible, of the transmission of disease and infection. The facility failed to investigate an employee with a communicable disease (Shingles) to assure she was not contagious, to assure she was safe to work in the dietary department, and to assure effective infection control precautions were implemented, if needed. This practice had the potential to affect all facility residents. Facility census: 55. Findings include: a) On 07/27/11, an allegation that someone in the kitchen was working with a communicable disease (specifically Shingles) was investigated. At 10:00 a.m., interviews were conducted with the facility's administrator (Employee #14), dietary manager (DM - Employee #20), and the person responsible for infection control (Employee #54), who was also the director of nursing (DON). These persons recalled a dietary employee (Employee #66) whom they said stated she had Shingles. According to Employee #20, Employee #66 had been released to return to work on 07/12/11. Further interview revealed the facility did not make any inquiries regarding the employee's Shingles. The statement from the employee, that she had Shingles, was the only information the facility had regarding Employee #66 and a [DIAGNOSES REDACTED]. Facility staff did not even know whether the employee had actually been diagnosed with [REDACTED]. The DON confirmed she heard the employee had Shingles when Employee #66 called off on 07/09/11. The DON stated she had assisted in securing coverage for Employee #66's position on that date. The DON confirmed she had not made any inquiries of the employee regarding the Shingles, at any time, to assure the employee was not contagious and could safely work at the facility. The DM also confirmed she was told by the employee she had Shingles, but the DM had not made any inquiries regarding whether the employee was contagious and/or whether she was safe to work. On 08/02/11 at 12:45 p.m., a telephone conversation was held with Employee #66, the employee with Shingles. This person confirmed she had informed the DM she had Shingles. Employee #66 stated no one at the facility made any inquiries regarding whether or not she was contagious. The employee also stated she had not informed the physician of what type of work she did. The facility provided a return to work release for 07/08/11 and another return to work release for 07/12/11, but neither indicated whether or not restrictions were needed and/or if the employee was safe to work in the dietary department. The facility failed to make reasonable efforts to assure Employee #66 was not contagious after she reported she had Shingles, and failed to assure she was safe to work in the dietary department during the period of time the employee stated she had Shingles.",2014-11-01
11037,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,323,E,0,1,ETK911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on water temperature measurements, staff interview, and observation, the facility failed to assure the residents' environment was as free of accident hazards as possible. Water temperatures were too hot in residents' hand sinks, a resident was not ambulated as ordered to prevent falls, and a treatment cart was left unlocked and unattended in the hallway. These practices had the potential to affect one (1) sampled resident and all residents who could ambulate independently. Resident identifier: #51. Facility census: 55. Findings include: a) Water temperatures On 05/22/09, temperatures of hot water were taken with the facility's environment services supervisor (ESS). The water temperatures were taken of the hand sinks on ""B,"" ""C,"" and ""D"" Halls, with the following findings which exceeded the maximum safe temperature (110 degrees F): - B-2 was 118 degrees F at 10:08 a.m. - C-3 was 116 degrees F at 10:10 a.m. - D-1 was 116.8 degrees F at 10:10 a.m. Interview with the ESS, at 9:45 a.m. on 05/22/09, revealed he mistakenly believed 110 degrees F was the minimum allowable temperature in resident areas, instead of the maximum allowable temperature. Record review revealed water temperatures were being taken, but the exact temperatures were not being recorded. A check mark was being placed beside 110 degrees F. According to the ESS, this check meant the hot water was 110 degrees F or above. b) Resident #51 Medical record review revealed an order for [REDACTED]. This information was also found on the closet sheet. At noon on 05/22/09, this resident was observed being ambulated to and from the dining room without being followed with a wheelchair, creating an accident hazard for this resident. c) Treatment cart On 05/21/09 at 11:45 a.m., random observations of the resident environment found s treatment cart parked in the ""C"" hallway with no staff members present in the hallway. Inspection of the treatment cart found it had been left unlocked and stocked with treatment supplies which included numerous creams and ointments. The treatment cart remained unsupervised and unlocked in the resident hallway for five (5) minutes. A nursing staff member was observed to exit a resident room, which previously had the door closed. She stated she had forgotten to lock her cart. .",2014-09-01
11038,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,332,D,0,1,ETK911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to assure medication were administered with an error rate below 5 percent (5%). Facility nursing staff members made three (3) medication errors with an opportunity for fifty-three (53) errors for an overall error rate of 5.6 %. This deficient practice affected three (3) of seven (7) residents receiving medications. Resident identifiers: #55, #37, and #35. Facility census: 55. Findings include: a) Resident #55 Observations of the medication administration pass, on 05/20/09 at 9:10 a.m., found the nurse pouring liquid Potassium into a plastic medication cup. Review of the medication administration record (MAR) noted the physician ordered Resident #55 to receive 7.5 cc of liquid Potassium. The nurse was asked to measure the amount of liquid Potassium present in the cup by using a syringe. The nurse determined the cup only contained 6.25 cc of liquid Potassium. b) Resident #37 Observation of the medication administration pass, on 05/21/09 at 9:15 a.m., found the nurse preparing medications for Resident #37. Review of the MAR noted the resident was to receive 150 mg of [MEDICATION NAME]. Inspection of the bottle of [MEDICATION NAME] utilized by the nurse revealed each tablet contained 75 mg. of [MEDICATION NAME]. The nurse placed one (1) tablet of [MEDICATION NAME] into the resident's medication cup and administered it to the resident along with her other medications. The nurse was asked to again review the MAR and bottle of medication following the administration. She agreed the she should have administered two (2) tablets of [MEDICATION NAME] to the resident. c) Resident #35 Review of the medical record found Resident #35 was prescribed [MEDICATION NAME] 120 mg three-times-a-day (TID) before each meal for treatment of [REDACTED]. Observations of the resident, on the morning of 05/21/09, found no nurse administered [MEDICATION NAME] prior to the noon meal. Review of the MAR, on 05/21/09 at 1:30 p.m., found a nurse had not initialed the [MEDICATION NAME] had been administered to the resident. An interview with the assigned nurse, on 05/21/09 at 1:30 p.m., confirmed the nurse did not administer the [MEDICATION NAME] prior to the noon meal. .",2014-09-01
11039,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,428,F,0,1,ETK911,"Based on medical record review and staff interview, the facility failed to assure a licensed pharmacist conducted a review of each resident's drug regimen at least once a month. This deficient practice affected all residents currently residing in the facility. Facility census: 55. Findings include: a) Review of thirteen (13) medical records found no evidence a licensed pharmacist conducted a drug regimen review for the month of April 2009. An interview with the director of nursing (DON), on the morning of 05/20/09, confirmed a drug regimen review was not conducted by a licensed pharmacist in April 2009. .",2014-09-01
11040,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,441,D,0,1,ETK911,"Based on random observation and review of facility policy, the facility failed to assure nurses administered eye drops in a manner to prevent the potential spread of infection for two (2) of two (2) eye drop administrations observed. Resident identifiers: #55 and #50. Facility census: 55. Findings include: a) Resident #55 During observations of the medication administration pass on 05/21/09 at 9:10 a.m., the nurse (Employee #52) administered eye drops to Resident #55. The nurse did not wash or sanitize her hands. She removed gloves from a box in the room, wadded them up in her hands, carried the resident's oral medications and bottle of eye drops into the resident's room, then removed another pair of gloves from the box in the room and placed them into her uniform pocket. The nurse administered the resident's oral medications. She then removed a pair of gloves from her uniform pocket, donned the contaminated gloves, and administered one (1) drop of medication into each of the resident's eyes. The director of nursing (DON) provided the facility's policy on the instillation of eye drops at 10:30 a.m. on 05/20/09. Review of the policy section entitled ""Infection Control Protocol and Safety"" (revised August 2002) found the following instructions: ""1. Wash your hands thoroughly with soap and water at the following intervals: a. before the procedure; ... ."" b) Resident #50 On 05/21/09 at 9:15 a.m., the nurse (Employee #30) administered eye drops to each of Resident #50's eyes. During this administration, the nurse allowed the tip of the eye drop bottle to come into contact with the lashes of the resident's left eye. .",2014-09-01
11041,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,502,D,0,1,ETK911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain laboratory services to meet the needs of one (1) of thirteen (13) sampled residents. Resident identifier: #1. Facility census: 55. Findings include: a) Resident #1 Review of the medical record found a physician's orders [REDACTED]. The medical record contained no evidence the facility had obtained the ordered laboratory test for this resident. An interview with the director of nursing (DON), on 05/21/09 at 12:00 p.m., confirmed the facility did not obtain the ordered laboratory test. .",2014-09-01
11042,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,225,E,0,1,ETK911,"Based on review of the facility's complaint records and staff interview, the facility failed to thoroughly investigate allegations of neglect upon receipt, and failed to report licensed healthcare professionals involved in instances of neglect to the appropriate licensing boards, and failed to assure staff immediately reported all allegations of neglect to the facility's administrator. These practices were evident for six (6) of ten (10) allegations reviewed. Resident identifiers: #5, #6, #35, #57, and #58. Facility census: 55. Findings include: a) Resident #6 On 01/06/09, Resident #6 reported to the facility she sometimes turned on her bathroom light and was not assisted for several minutes. The facility interviewed assigned nursing assistants and took statements. In one (1) of these statements, a nursing assistant identified by name another nursing assistant who had also helped the resident on the 7-3 shift on 01/06/09. The facility did not interview this other nursing assistant and/or obtained a statement from him/her. b) Resident #35 On 01/30/09, Resident #35's family expressed concern that the resident might not be getting showers on her scheduled shower days. The facility's investigation indicated statements were collected from nursing staff; however, upon request, the facility could not produce these statements. On 03/10/09, this resident's family again expressed concern that the resident was not receiving her scheduled showers. There was no investigation of this allegation; the facility only obtained statements from staff regarding what was supposed to occur regarding residents and their shower days. In addition, the family also expressed concern that the resident's personal items were being used for other residents. This concern was not addressed at all. c) Resident #5 On 02/20/09, Resident #5 reported she had not been receiving her medications for her mouth since admission on 02/05/09. The facility investigated the situation and disciplined several nurses for failing to order the medication and/or failing to assure the resident received the medication as ordered; however, the facility did not report the nurses involved in this neglect to the appropriate licensing board. d) Resident #57 On 03/04/09, the nursing assistant for this resident (who no longer resides in the facility) provided a statement indicating she had informed C.L., a licensed practical nurse (LPN), the resident had a scratch on her leg which needed to be checked by the LPN. The facility investigated the situation and substantiated the LPN did not assess the resident's leg. The facility did not report this neglect to the appropriate licensing board. e) Resident #58 On 03/02/09, a nursing assistant (Employee #17) made a complaint regarding C.L. (LPN) regarding the nurse's failure to check on Resident #58. The nursing assistant stated, ""Around a week and a half ago ... she (the resident) was really pale in color and had diarrhea X 6."" The nursing assistant stated the LPN did not do anything for the resident after she was given this information. The nursing assistant did not immediately report this allegation of neglect to facility administration, and there was no evidence this failure to report was addressed. f) During an interview on the afternoon of 05/20/09, the social worker was unable to provide any additional information regarding the above-referenced concerns. .",2014-09-01
11043,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,364,F,0,1,ETK911,"Based on observation and staff interview, the facility failed to assure potatoes were prepared by a method which conserved nutritional value. They were soaked in water, creating a loss of nutrients. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 55. Finding include: a) On 05/18/09 at 2:00 p.m., observation revealed a large pan of potatoes in a large amount of water in the cooler. Upon inquiry, at that time, the cook stated the potatoes were for the following day. Further inquiry revealed the water would be drained off and discarded. This practice creates a loss of potassium in the potatoes. This process is called ""leaching"" and is used when potassium needs to be removed from potatoes for potassium restricted diets.",2014-09-01
11044,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,315,D,0,1,ETK911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, the facility failed to provide services and treatment to restore as much normal bladder function as possible for one (1) of twelve (12) sampled residents. The facility did not assess one (1) of thirteen (13) sampled residents or put individualized measures in place to help restore continence when a resident had a decline in bladder continence. Resident identifier: #12. Facility census: 55. Findings include: a) Resident #12 Medical record review, on 05/20/09, revealed this resident had an indwelling Foley urinary catheter when she was admitted on [DATE]. The facility implemented a bladder training schedule for discontinuation of the catheter on 08/20/08, 08/21/08 and 08/23/08, and the catheter was discontinued at 12:00 a.m. on 08/23/08. A bladder assessment was completed on 10/13/08. This assessment indicated the resident was continent of bladder. Review of the resident's minimum data set assessment (MDS), with an assessment reference date (ARD) of 02/08/09, revealed the resident's bladder continence was coded ""2"", indicating occasional bladder incontinence. This coding represents incontinence two (2) or more times a week, but not daily. Review of the resident's MDS, with an ARD of 05/03/09, revealed the resident was coded ""3"", indicating frequent bladder incontinence. This coding represents incontinence daily. Review of the resident's care plan, dated 05/05/09, revealed the following problem: ""Having incontinence of bowel and bladder which has worsened."" The interventions for this problem did not include anything regarding assessment for causal factors. The interventions described the resident had declined a toileting schedule. There was no evidence of any other plans to assist the resident in becoming continent and/or less incontinent. The facility's urinary continence and incontinence assessment and management policy, provided by the director of nursing (DON), instructed facility staff to complete ongoing assessments of a resident's diagnoses, physical and cognitive functioning, and environment factors, to name a few, to determine possible causal factors for incontinence. The policy also directed staff to identify risk factors, complete a review of medications, assess voiding patterns, and to identify other risk factors for becoming incontinent or for worsening of current incontinence. There was no evidence that this had been done for this resident. On 05/22/09 at 3:30 p.m., a discussion was held with the DON regarding this resident's incontinence and what assessment the facility had initiated to determine causal factors and/or appropriate plans to assist the resident in becoming continent, or less incontinent. At that time, the DON had no additional information to provide regarding what the facility had implemented to assess whether this resident's worsening incontinence had the potential to be reversed. .",2014-09-01
11045,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2009-05-22,246,D,0,1,ETK911,"Based on observation and staff interview, the facility failed to made reasonable accommodations with staff's routine and/or practices to ensure residents received timely assistance with toileting to maintain independent functioning and dignity. This affected two (2) residents of random observation. Resident identifiers: #39 and #51. Facility census: 55. Findings include: a) Residents #51 and #39 After the noon meal on 05/22/09 at 1:45 p.m., observation found Resident #51 waiting for a staff member to take her to the bathroom. Upon inquiry, the resident stated she had already asked staff to take her, but they have not ""gotten to me yet"". The resident then stated, ""If I don't go to the bathroom soon, I'm gonna go. I know what everyone feels like now when they've gotta go and no one to take them."" Further discussion revealed staff told the resident she would have to wait until the trays were picked up to be taken to the bathroom. A few minutes later, the resident was taken to her room and into the bathroom. While Resident #51 was in the bathroom, her roommate (Resident #39) was brought to the entrance of their room to be taken to the bathroom. When Resident #39 was informed Resident #51 was in the bathroom, Resident #39 stated she had to go ""now"" and ""I am about to wet myself."" A nursing assistant and a nurse were just outside the door when this occurred. When asked what should be done in this situation, the nurse stated, ""That's a good question. This has not come up before."" Neither nursing staff member considered, or took, Resident #39 to a different bathroom. .",2014-09-01
11261,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2011-03-16,157,D,1,0,R8P711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of medical records, staff interviews, observations, and resident comments, the facility failed to notify the physician of a resident's repeated refusal of [MEDICATION NAME] eye drops (for reduction of elevated pressure in the eyes). The facility also failed to notify the responsible party when a resident was sent out for an appointment at a local hospital for repair of her [MEDICAL TREATMENT] access. Two (2) of thirty-four (34) residents on the Stage II sample were affected. Resident identifiers: #13 and #11. Facility census: 55. Findings include: a) Resident #13 During observation of medication administration pass on 03/08/11 at 8:37 a.m., Employee #21, a registered nurse (RN), took Resident #13's [MEDICATION NAME] eye drops to the bedside. The nurse asked the resident if she wanted to take the eye drops that morning. The resident declined the eye drops, saying she did not need them at that time. The nurse did not ask the resident why she did not want to take the eye drops, nor did she advise the resident the purpose of the drops. (The resident also had orders for natural tears.) - Review of this [AGE] year old woman's medical record found she had [DIAGNOSES REDACTED]. 365.9 - Unspecified [MEDICAL CONDITION] 374.05 - Trichiasis of eyelid without entropion 375.15 - Unspecified tear film insufficiency 366.9 - Unspecified cataract - On 03/15/11 at approximately 3:30 p.m., review of the nursing entries (which reflected the reasons for medications not being administered noted on the electronic Medication Administration Record [REDACTED] - 03/14/11 at 08:52 - ""[MEDICATION NAME] - 1 drop both eyes q (every) day : Refused med."" - 03/13/11 at 09:46 - ""[MEDICATION NAME] - 1 drop both eyes q day : Refused med."" - 03/12/11 at 10:09 - ""Patient requested not to have eye drops in."" - 03/08/11 at 08:38 - ""[MEDICATION NAME] - 1 drop both eyes q day : Pt. (patient) refused eye drops states she does not need the right now."" - 03/07/11 at 08:42 - ""[MEDICATION NAME] - 1 drop both eyes q day : refused states it makes her eyes feel funny."" - 02/27/11 at 09:43 - ""[MEDICATION NAME] - 1 drop both eyes q day : refused states 'I dont (sic) take them any more."" - 02/25/11 at 09:15 - ""[MEDICATION NAME] - 1 drop both eyes q day : resident refused [MEDICATION NAME] eye drops."" - 02/22/11 at 08:32 - ""[MEDICATION NAME] - 1 drop both eyes q day : Refused eye drops states 'I quit taking those they make my eyes worse."" - 02/21/11 at 09:03 - ""[MEDICATION NAME] - 1 drop both eyes q day : refused med this am (morning)."" - 02/20/11 at 09:42 - ""[MEDICATION NAME] - 1 drop both eyes q day : Resident refused eye drops today."" - 02/12/11 at 09:03 - ""[MEDICATION NAME] - 1 drop both eyes q day : refused [MEDICATION NAME] eye drops."" - 02/08/11 at 08:20 - ""[MEDICATION NAME] - 1 drop both eyes q day : Refuses [MEDICATION NAME] eye drops."" In January 2011, the [MEDICATION NAME] was held on 01/24/11, 01/23/11, 01/16/11, 01/10/11, and 01/09/11. - A ""Physician's Contact Note"", dated 12/28/11 at 18:25, noted: ""Complaints of eyes burning, refusing [MEDICATION NAME] dye drops, appetite decreased. Dr. ____ in to see resident today."" At that time, the resident was assessed as having [MEDICAL CONDITION] and antibiotic eye drops were ordered. No further evidence was found indicating the physician had been notified of the resident's continued intermittent refusal of the [MEDICATION NAME] eye drops. There was no indication the resident was told the drops were for her [MEDICAL CONDITION]. - Review of the resident's current care plan found no care planning relative to the resident's refusal of the [MEDICATION NAME] eye drops. - Review of information about [MEDICATION NAME] at http://www.[MEDICATION NAME].com/content/index.aspx found: ""[MEDICATION NAME] is indicated for the reduction of elevated intraocular pressure in patients with open-angle [MEDICAL CONDITION] or ocular hypertension ... [MEDICATION NAME] offers easy once-a-day use ... ""[MEDICATION NAME] is an eyedrop that lowers pressure in the eye. You don't usually feel eye pressure, but if it is too high, it can damage the optic nerve and cause vision loss. [MEDICATION NAME] is your partner in the fight against high eye pressure which can lead to [MEDICAL CONDITION]. ..."" - Notification of the physician when a resident refuses medications was discussed with Employee #78 (an RN) at 10:00 a.m. on 03/16/11. She said she thought the resident had to refuse three (3) days in a row before the physician was contacted. Employee #76 (the minimum data set coordinator) was in the room at this time. Employee #76 asked her if it had to be three (3) days before the physician was notified of a resident refusing medications, but Employee #78 said she did not know. -- b) Resident #11 Medical record review for Resident #11, conducted on 03/09/11, revealed Resident #11 received [MEDICAL TREATMENT] on an outpatient basis due to having [MEDICAL CONDITION]. A [MEDICAL TREATMENT] communication sheet, filled out by the [MEDICAL TREATMENT] center on 12/26/10, indicated the physician at the [MEDICAL TREATMENT] center had scheduled the resident to go out to a local hospital on [DATE] for a surgical procedure. A nursing note, dated 12/26/10 at 3:58 p.m., stated, ""Pre/Post [MEDICAL TREATMENT] Weight: Pere (sic) weight -85.1kg. Resident attended [MEDICAL TREATMENT], but they were unable to access her. She was sent back without receiving treatment. She is scheduled to meet with the Doctor in out patient at (name of hospital) to have her Quinton catheter checked. Will be NPO (nothing by mouth) after midnight and will be picked up by (name of ambulance company) at 5:00 a.m."" During an interview on 03/09/11 at approximately 1:00 p.m., the director of nursing (Employee #79) reported she felt the nursing staff at the facility needed to contact the responsible party even if the [MEDICAL TREATMENT] center made the appointment. Resident #11 did not have capacity to understand and make informed health care decisions, and her sorrugate decision-maker was not informed of the appointment. .",2014-07-01
11476,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2010-10-14,164,E,,,S21C11,". Based on observation, staff interview, and a confidential resident group interview, the facility failed to ensure resident privacy was maintained during showers. The men's and women's shower rooms shared a common whirlpool area, and the privacy curtains separating these areas could not be pulled closed to ensure privacy during bathing. This had the potential to affect any resident showered in the central shower rooms at the facility. Facility census: 56. Findings include: a) During a tour of the facility on 10/13/10 at 2:00 p.m., the men's and women's shower rooms were visited by two (2) health facility surveyors. The doors to the shower rooms were separate, but once inside the shower rooms, the men's and women's rooms were connected via a common whirlpool area with full visual access from either side. There were tracks for two (2) sets of privacy curtains, one (1) on either side of the whirl pool area. The only side that had privacy curtains was located on the women's side, and one (1) of the surveyors was unable to pull closed the privacy curtains on this side. The privacy curtains were observed with the facility's administrator at 2:05 p.m. with both surveyors present. The administrator reported that men and women were not showered at the same time. Two (2) nursing assistants (Employees #7 and #54), whom the administrator indicated were shower aides for that day, were interviewed. They indicated they showered about thirty (30) residents on that particular day and finished before noon. They said they did not shower men and women at the same time. During a resident group interview on 10/14/10 at approximately 3:00 p.m., two (2) of four (4) female residents in the group reported they were given showers within the past week while men were in the common shower area at the same time. They reported the privacy curtains could not be pulled all the way closed in order to prevent others from observing while they are taking a shower. They also reported they were able to see the male residents in the shower. This was confirmed during a second observation by one (1) of the health facility surveyors just after the group interview.",2014-02-01
11534,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2010-09-09,157,D,,,0TPT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, an interview with the family nurse practitioner, and medical record review, the facility failed to notify the health care decision maker for one (1) of six (6) sampled residents after the resident's oral medications were discontinued. Resident identifier: #59. Facility census: 55. Findings include: a) Resident #59 A review of the physician's orders [REDACTED]. Documentation on the physician's orders [REDACTED].#59 of the changes in the resident's medications. This was confirmed by an interview with the FNP and the resident's attending physician at 9:00 a.m. on 09/09/10. The FNP said the medications were discontinued after the FNP had a discussion with the MPOA. She said she told the MPOA she would evaluate the resident's ability to swallow and then decide if she was going to discontinue the oral medications. She said she went into the resident's room, sat the resident up in the bed, and gave the resident a drink of water. This was documented on a progress note written by the FNP on 08/19/10. The 08/19/10 progress note stated: ""Chief complaint: F/U (follow-up) CXR (chest x-ray) (8/18/10) and F/U lethargy (8/18). CXR impression with New findings of subtotal collapse of right lung, possibly due to mucous plug or occult [MEDICATION NAME] lesion. ""Neuro: Unchanged: lethargic, but will open eyes and speak when stimulated. ""Neuro Addendum: Assessed swallowing, sat her up in bed at 90 degrees, tilted head forward, she drank 2 oz, but then coughed. ""Impression: Stable chronic Problems: End stage lung CA. Terminal condition. Prognosis Poor. Suspect dysphagia and high risk for aspiration. ""Plan: No change in Care Today: Called (Resident #59's MPOA) on her cell phone and updated (Resident #59's) condition. Report CXR results, VS and physical exam findings. Requested [MEDICATION NAME] give for possible 'pneumonia' Advised that [MEDICATION NAME] will probably not change outcome but will order it. (Resident #59's MPOA) stated, 'I just want her comfortable and not afraid...'"" The FNP said the resident was unable to swallow, so she discontinued all of the oral medications for the resident, except for two (2) which were inadvertently missed while reviewing the medications. These were [MEDICATION NAME] and [MEDICATION NAME]. The physician's orders [REDACTED]. She also did not tell the facility's nursing staff to contact the MPOA. During an interview on 09/08/10 at 1:45 p.m., Employee #58 (a licensed practical nurse - LPN), who was present at the nursing station on 08/19/10 when the FNP spoke with Resident #59's MPOA, said she thought the FNP was going to discontinue the resident's oral medications. She said the FNP was going to evaluate the resident. Employee #58 thought the FNP told the MPOA that she was going to discontinue the medications. During an interview on 09/09/10 at 9:40 a.m., the matter of Resident #59's MPOA was not notified after the resident's oral medications were discontinued on 08/19/10 was discussed the director of nursing (DON). The DON said the first time she became aware that the MPOA had not been notified of the discontinuation of oral medications was on 08/22/10, when the attending physician did not want to restart the medications. .",2014-01-01
11535,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2010-09-09,281,D,,,0TPT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and a review of the facility's policy regarding medication administration, the facility failed to ensure that medications were given as ordered by the physician. Resident #59 did not receive Tylenol every six (6) hours for three (3) days as ordered by the attending physician. Resident identifier: #59. Facility census: 55. Findings include: a) Resident #59 A review of the August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR failed to find evidence this medication was administered on 08/20/10 for the 12:00 a.m. and 6:00 a.m. doses. The entries for those time periods were left blank. A review of the reverse of the MAR indicated [REDACTED]. Review of the nurse's notes written during this time period, on 08/19/10 at 10:00 p.m. and on 08/20/10 at 4:00 a.m., found no mention of this medication having been given or refused. Interviews and review of the August 2010 MAR indicated [REDACTED]. The administrator provided a copy of the Nurse's 24-Hour Report for 08/20/10 for the midnight shift, which contained a notation indicating the resident refused the suppository, but the notation did not indicate a specific time. A review of the 2001 ""Administering Medication"" policy (Revised 09/05 and 07/01/06) found Item #12 stated, ""Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication mus initial and circle the MAR indicated Item #14 of this policy stated, ""Any explanatory note on the reverse side of the MAR must be entered when drugs are withheld, refused, or given other than at scheduled times."" .",2014-01-01
11536,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2010-09-09,514,D,,,0TPT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and review of facility policy, the facility failed to maintain clinical records for each resident that were complete and accurately documented in accordance with facility policy, for one (1) of six (6) sampled residents. Resident identifier: #59. Facility census: 55. Findings include: a) Resident #59 A review of the August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR failed to find evidence this medication was administered on 08/20/10 for the 12:00 a.m. and 6:00 a.m. doses. The entries for those time periods were left blank. A review of the reverse of the MAR indicated [REDACTED]. Review of the nurse's notes written during this time period, on 08/19/10 at 10:00 p.m. and on 08/20/10 at 4:00 a.m., found no mention of this medication having been given or refused. Interviews and review of the August 2010 MAR indicated [REDACTED]. The administrator provided a copy of the Nurse's 24-Hour Report for 08/20/10 for the midnight shift, which contained a notation indicating the resident refused the suppository, but the notation did not indicate a specific time. A review of the 2001 ""Administering Medication"" policy (Revised 09/05 and 07/01/06) found Item #12 stated, ""Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication mus initial and circle the MAR indicated Item #14 of this policy stated, ""Any explanatory note on the reverse side of the MAR must be entered when drugs are withheld, refused, or given other than at scheduled times.""",2014-01-01
1888,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2019-02-13,554,D,0,1,DR1J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random opportunity for discovery, through observation, resident interview and staff interview, the facility failed to ensure Resident #148 had been assessed to self administer medications prior to having medication remain at the bedside. Resident identifier: #148. Facility census: 99. Findings included: a) Resident #148 During the initial tour, on 2/11/19, at 11:11 AM, R#148 was observed in bed and a [MEDICATION NAME] inhaler was laying on the resident's bedside table in plain view. Further interview with R#148, on 02/11/19, at 7:30 AM, revealed R#148 uses the [MEDICATION NAME] inhaler and nebulizer to control his breathing problems. A review of the medical record , conducted 02/12/19, noted no current order for a [MEDICATION NAME] inhaler and no assessment could be located in the medical record. A review of the Med reconciliation UDA-V1, dated 02/10/19, noted R#148 had been on medication at home and listed respiratory drugs as one of the classifications. An interview, on 02/12/19, at 03:20 PM, with the Director of Nursing (DON), revealed there had been no self-administration assessment completed to determine if the resident was capable of self-administering the [MEDICATION NAME] inhaler observed at the bedside. Additionally, the DON stated there was no order for the [MEDICATION NAME] inhaler R#148 had been using and she was not aware he had the medication. A further interview, on 02/13/19, at 09:15 AM, with the DON, verified this practice was wrong. A review of the policy, Resident Self-Administration of Medication, no revision date, noted Each resident who desires to self-administer medication may be permitted to do so if the Center's interdisciplinary team has determined that the practice would be safe for the resident and other residents at the Center.",2020-09-01
1889,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2019-02-13,583,D,0,1,DR1J11,"Based on staff interview and observation, the facility failed to ensure a medication packet with a pharmacy label was disposed of in a manner that protected personal, medical, and health information. Personal identifiers including the resident's name, medication, and physician, were listed on the pharmacy label. This was a random observation. Resident identifier: #68. Facility census: 99. Findings included: a) Resident #68 A random observation of Nutter Hall, on 02/13/19 at 8:10 AM, revealed one (1) empty medication packet, with the pharmacy label still attached, lying on the counter at the nurses station. The medication packet was visible for anyone walking past to see. The resident's medication packet contained the following information: -Resident's name -Medication -Physician An interview with Licensed Practical Nurse (LPN) #76, on 02/13/19 at 8:15 AM, revealed the medication packet should have never been laid upon the counter at the nurses station. The LPN stated the pharmacy labels are usually removed from the medication packet and shredded. The LPN stated she had no idea who laid the packet on the counter.",2020-09-01
1890,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2019-02-13,584,E,0,1,DR1J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment for residents. Resident rooms were not clean or in good repair. This practice affected ten (10) of fifty-seven (57) rooms observed during the Long Term Care Survey Process (LTCSP). Room identifiers: #100, #101, #107, #108, #114, #118, #204, #211, #213, and #215. Facility census: 99. Findings included: a) Observations The following observations were made during the LTCSP on 02/11/19, 02/12/19, and 02/13/19: --room [ROOM NUMBER] The floor was very sticky to walk on. The door to the bathroom was broken and chipped by the door closure. The commode needed caulked at the floor. --room [ROOM NUMBER] The wall was damaged by the air/heating unit on the left side. The commode near the floor needed caulked. The mirror base was damaged and dark. The wall under the tv was scuffed. The wall outside of the room in the hallway had a gouge by the fire alarm. --room [ROOM NUMBER] There were cracks around the air/heating unit. The area around the sink was cracked and chipped. --room [ROOM NUMBER] The bathroom mirror was damaged. The area behind the sink needed caulked. --room [ROOM NUMBER] The door was chipped where the door latched. The mirror glass was discolored. --room [ROOM NUMBER] There was a crack on the right side of the wall and window seal near the air/heating unit. The mirror was dark and damaged at bottom of glass. --room [ROOM NUMBER] The wall above the air/heating unit was damaged and missing paint. The bathroom wall by the sink was missing paint. --room [ROOM NUMBER] The paint was missing by the vent on the bathroom ceiling. The wall beside the toilet was missing paint. There was feces on the toilet seat. The paint was missing on the wall by the sink. --room [ROOM NUMBER] The floor beside the bed was stained. --room [ROOM NUMBER] The bathroom wall was scraped and chipped in several areas. b) Interview An interview with the Maintenance Director (MD), on 02/13/19 at 11:30 AM, revealed resident room rounds are supposed to be completed every thirty days. The MD stated I am doing the best I can with maintenance issues considering I'm covering four departments by myself right now. The MD stated he was currently in charge of central supply, maintenance, housekeeping, and laundry. The MD stated he knew there was some issues that needed corrected but could only do what he could with the time he had.",2020-09-01
1891,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2019-02-13,657,D,0,1,DR1J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure a comprehensive care plan had been revised to reflect a discontinued medication. This was found true for one (1) of 26 care plans reviewed during the Investigation process of the survey. The care plan for R74 had not been revised to reflect the discontinued use of [MEDICATION NAME]. Resident identifier: #74 Facility census: 99. Findings included: a) Resident #74 A medical record review for R74 on 02/13/19 revealed a comprehensive care plan with the Focus: [MEDICATION NAME]: Risk for toxicity, complications due to [MEDICATION NAME] use related to [DIAGNOSES REDACTED]. Further review revealed an order to discontinue the use of [MEDICATION NAME] on 11/06/18. Therefore, the facility failed to revise the care plan for R74 for the discontinued use of the medication. In a interview on 02/13/19 at 1:55 PM with the Director of Nursing (DON) verified the Care Plan for R74 had not been revised to reflect the discontinued use of [MEDICATION NAME].",2020-09-01
1892,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2019-02-13,684,E,0,1,DR1J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, resident interview, and policy and procedure review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice, the comprehensive person-centered care plan and resident's choice for four (4) of 26 residents reviewed. R# 148 did not have orders or an assessment prior to the medications being self-administered by the resident and oxygen therapy was being administered without orders or was not provided in accordance with the physician's orders [REDACTED].#246 and R#17. Resident identifiers: #148, #147, #246 and #17. Facility census: 99. Findings included: a.) R #148 During the initial tour, on 2/11/19, at 11:11 AM, R#148 was observed in bed and a [MEDICATION NAME] inhaler was laying on the resident's bedside table in plain view. Further interview with R#148, on 02/11/19, at 7:30 AM, revealed R#148 uses the [MEDICATION NAME] inhaler and nebulizer to control his breathing problems. A review of the medical record , conducted 02/12/19, noted no current order for a [MEDICATION NAME] inhaler and no assessment could be located in the medical record. A review of the Med reconciliation UDA-V1, dated 02/10/19, noted R#148 had been on medication at home and listed respiratory drugs as one of the classifications. An interview, on 02/12/19, at 03:20 PM, with the Director of Nursing (DON), revealed there had been no self-administration assessment completed to determine if the resident was capable of self-administering the [MEDICATION NAME] inhaler observed at the bedside. Additionally, the DON stated there was no order for the [MEDICATION NAME] inhaler R#148 had been using and she was not aware he had the medication. A further interview, on 02/13/19, at 09:15 AM, with the DON, verified this practice was wrong. A review of the policy, Resident Self-Administration of Medication, no revision date, noted Each resident who desires to self-administer medication may be permitted to do so if the Center's interdisciplinary team has determined that the practice would be safe for the resident and other residents at the Center. b.) R #147 An observation, on 02/11/19, at 03:30 PM, revealed R#147 was receiving oxygen by nasal cannula at four (4) liters per minute (4 L/min) as verified with COTA#96. An observation, on 02/12/19, at 01:35 PM, revealed R#147 was receiving oxygen by nasal cannula at 4 L/min as verified by LPN #56. A review of the medical record on 02/12/19 at 14:53 hours noted no current order for R#147 to be receiving oxygen at 4 L/min per nasal cannua. An interview with the Director of Nursing (DON) on 02/13/19,at 02:18 PM, revealed the DON stating there was an order in place for the oxygen, however, when requested to review the order, it was noted to be written on 02/12/19 at 19:00 hours after surveyor observations with staff were conducted. A review of the policy and procedure for Oxygen Administration notes in order to provide safe oxygen administration, Verify physicians order for the procedure. c) R246 A review of the medical record review on 02/12/19 for R246 had a physician's orders [REDACTED]. During an observation for R246 on 02/12/19 at 3:04 PM, it was discovered his oxygen concentrator was set on five (5) liters of oxygen. R246 was receiving a flow rate of five (5) liters per minute via a nasal cannula and not the prescribed two (2) liters per minute via nasal cannula. At 3:10 PM on 02/12/19, Employee #76, licensed practical nurse (LPN) verified R246 was receiving his oxygen at the flow rate of five (5) liters per minute and not the prescribed two (2) liters. d) Resident #17 Interviewed Licensed Practical Nurse (LPN) #87 on 02/11/19 at 2:04 PM LPN # 87 stated Resident #17 was having a decline in oxygen levels. LPN #87 stated that an oxygen mask was used for Resident #17 due to a decline in oxygen levels. Reviewed Resident #17's physician orders [REDACTED]. Order stated continuous oxygen at 2 liters per nasal cannula, monitor SPO2 every shift. Reviewed River Oaks Oxygen Administration Policy. Policy stated Set the oxygen according to physician's orders [REDACTED].g., mask, nasal cannula). On 02/12/19 03:25 PM, Resident #17 was observed wearing an oxygen mask at an oxygen flow rate of two and a half (2.5) liters. Interviewed Licensed Practical Nurse (LPN) #76 and Assistant Director of Nursing (ADON) on 02/12/19 at 3:44 PM. LPN #76 confirmed physician order [REDACTED]. LPN #76 stated that Resident #17 had been ordered three (3) liters of oxygen started 02/12/19. LPN #76 confirmed that two and half (2.5) liters of oxygen was not a correct flow rate. ADON stated the Nurse Practitioner gave a verbal order that Resident #17 was to wear an oxygen mask started for 02/12/19. LPN #76 stated that she would be putting the physician order [REDACTED].",2020-09-01
1893,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2019-02-13,689,E,0,1,DR1J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interviews and policy review the facility failed to keep resident's environment free of accident hazards as possible. A medication cart was found unlocked on the 400 hallway and R148 had an inhaler at his bedside. This practice had the potential to affect more than a limited number of residents. Resident identifier: #148 Facility census: 99. Findings included: a) Unlocked medication cart During a random opportunity for discovery on 02/11/19 at 11:03 AM a medication cart parked on the 400 hallway was found unlocked. This unsafe practice allowed any mobile resident access to medications in this cart. On 02/11/19 at 11:05 AM Employee #155 licensed practical nurse (LPN) locked the medication cart which allowed any mobile resident unsafe access to medications in this cart. b.) R #148 During the initial tour, on 2/11/19, at 11:11 AM, R#148 was observed in bed and a [MEDICATION NAME] inhaler was laying on the resident's bedside table in plain view. Further interview with R#148, on 02/11/19, at 7:30 AM, revealed R#148 uses the [MEDICATION NAME] inhaler and nebulizer to control his breathing problems. A review of the medical record , conducted 02/12/19, noted no current order for a [MEDICATION NAME] inhaler and no assessment could be located in the medical record. A review of the Med reconciliation UDA-V1, dated 02/10/19, noted R#148 had been on medication at home and listed respiratory drugs as one of the classifications. An interview, on 02/12/19, at 03:20 PM, with the Director of Nursing (DON), revealed there had been no self-administration assessment completed to determine if the resident was capable of self-administering the [MEDICATION NAME] inhaler observed at the bedside. Additionally, the DON stated there was no order for the [MEDICATION NAME] inhaler R#148 had been using and she was not aware he had the medication. A further interview, on 02/13/19, at 09:15 AM, with the DON, verified this practice was wrong. A review of the policy, Resident Self-Administration of Medication, no revision date, noted Each resident who desires to self-administer medication may be permitted to do so if the Center's interdisciplinary team has determined that the practice would be safe for the resident and other residents at the Center. Resident #148 had medications at the bedside without an order or an assessment deeming self- administration of the medication was safe for R #148 and other residents at the facility.",2020-09-01
1894,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2019-02-13,695,E,0,1,DR1J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview, and policy review, the facility failed to deliver respiratory care services consistent with professional standards of practice. Residents receiving oxygen had no orders, were receiving the wrong rate, had on the wrong device, and had their oxygen supplies on the floor. These practices affected four (4) of nine (9) residents reviewed for respiratory care during the Long Term Care Survey Process (LTCSP). Resident identifiers: #17, #89, #147, and #246. Facility census: 99. Findings included: a) Resident #89 An observation of the Resident, on 02/11/19 at 11:15 AM, revealed the Resident's nasal cannula and tubing was on the floor under the bed. An interview with the Resident, on 02/11/19 at 11:16 AM, revealed her oxygen had been on the floor for a while. An interview with Director of Nursing (DON), on 02/11/19 at 11:25 AM, revealed the nasal cannula used for oxygen should never be on the floor. The DON removed the oxygen from the floor. b) R #147 An observation, on 02/11/19, at 03:30 PM, revealed R#147 was receiving oxygen by nasal cannula at four (4) liters per minute (4 L/min) as verified with COTA#96. An observation, on 02/12/19, at 01:35 PM, revealed R#147 was receiving oxygen by nasal cannula at 4 L/min as verified by LPN #56. A review of the medical record on 02/12/19 at 14:53 hours noted no current order for R#147 to be receiving oxygen at 4 L/min per nasal cannua. An interview with the Director of Nursing (DON) on 02/13/19,at 02:18 PM, revealed the DON stating there was an order in place for the oxygen, however, when requested to review the order, it was noted to be written on 02/12/19 at 19:00 hours after surveyor observations with staff were conducted. A review of the policy and procedure for Oxygen Administration notes in order to provide safe oxygen administration, Verify physicians order for the procedure. Oxygen orders were not obtained for R#147 until after two (2) observations had been made on two (2) consecutive days of the resident receiving oxygen by nasal cannula. c) R246 A review of the medical record review on 02/12/19 for R246 had a physician's orders [REDACTED]. During an observation for R246 on 02/12/19 at 3:04 PM, it was discovered his oxygen concentrator was set on five (5) liters of oxygen. R246 was receiving a flow rate of five (5) liters per minute via a nasal cannula and not the prescribed two (2) liters per minute via nasal cannula. At 3:10 PM on 02/12/19, Employee #76, licensed practical nurse (LPN) verified R246 was receiving his oxygen at the flow rate of five (5) liters and not the prescribed two (2) liters. d) Resident #17 Interviewed Licensed Practical Nurse (LPN) #87 on 02/11/19 at 2:04 PM. LPN #87 stated Resident #17 was having a decline in oxygen levels. LPN #87 stated that an oxygen mask was used for Resident #17 due to a decline in oxygen levels. Reviewed Resident #17's physician orders [REDACTED]. Order stated continuous oxygen at 2 liters per nasal cannula, monitor SPO2 every shift. Reviewed River Oaks Oxygen Administration Policy. Policy stated Set the oxygen according to physician's orders [REDACTED].g., mask, nasal cannula). On 02/12/19 03:25 PM, Resident #17 was observed wearing an oxygen mask at an oxygen flow rate of two and a half (2.5) liters. Interviewed Licensed Practical Nurse (LPN) #76 and Assistant Director of Nursing (ADON) on 02/12/19 at 3:44 PM. LPN #76 confirmed physician order [REDACTED]. LPN #76 stated that Resident #17 had been ordered three (3) liters of oxygen started 02/12/19. LPN #76 confirmed that two and a half (2.5) liters of oxygen was not a correct flow rate. ADON stated the Nurse Practitioner gave a verbal order that Resident #17 was to wear an oxygen mask started for 02/12/19. LPN #76 stated that she would be putting the physician order [REDACTED].",2020-09-01
1895,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2019-02-13,812,E,0,1,DR1J11,"Based on observation and staff interview, the facility failed to provide proper and sanitary food handling when serving food in the dining room. Staff handled food and non food items with the same gloved hands. The failed practice had the potential to affect more than a limited number of residents. Facility census: 99. a) Dining Room In observation of the dining room on 02/11/19 at 11:50 AM Cook #2 was observed cross contaminating food while touching food items and non food items with the same gloved hands. Cook #2 was observed touching the tops of the countertops then handled the tops of the plates. Without changing gloves, Cook # 2 touched the outside of the bun wrapper then was observed holding a bun without utensils as a philly cheese steak sandwich was made. When pulling the hot food out of the food warmer with cloths Cook #2 was observed cleaning the countertops off with the cloths. Cook #2 continued to use those cloths to pull out food containers from the food warmer. Cook # 2 touched the dirty cloths then was observed serving and touching plates again. Interviewed Cook # 2 on 02/11/19 at 12:40 PM regarding the process of serving food in the dining room. Cook # 2 stated that cross contaminated meant to not touch any door knobs but stated I never really thought about touching the counter tops as cross contaminating Cook #2 stated I didn't know I couldn't do that, I never thought about that. Cook #2 stated she had only worked in the facility since (MONTH) (YEAR). Cook #2 confirmed she cross contaminated and stated she was unaware she was doing so. Cook #2 also confirmed she pulled the food containers from the hot bar with cloths and wiped down the top of bar with cloth. Cook #2 confirmed touching the top of the plates but mostly with thumbs. Cook #2 stated she did not realize touching the dirty cloths and then the plates on top with her thumbs was cross contamination. Interviewed the Dietary Manager (DM) on 02/13/19 at 1:36 PM regarding serving food in the dining room . DM stated that he was aware of the glove issue observed on 02/11/19 with the handling of food and non food items in the dining room. DM confirmed that using the same gloves to handle both food and non food items was an incorrect procedure. DM stated he already pulled out information and procedures regarding cross contamination to retrain staff.",2020-09-01
1896,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2019-02-13,880,E,0,1,DR1J11,"Based on observation and staff interview, the facility failed to provide a safe and sanitary environment that prevented the development and transmission of communicable diseases and infections. Oxygen supplies being used by Resident #89 were on the floor, the Laundry Room did not have a barrier between the clean and dirty areas, lift pads that were on the floor were placed on the clean laundry storage shelves, and used mop heads and soiled towels were lying on top of barrels used to transport the clean laundry. These practices had the potential to affect more than a limited number of residents. Facility census: 99. Findings include: a) Laundry Room An observation of the Laundry Room, on 02/13/19 at 10:30 AM, revealed there was no barrier between the clean and dirty sections of the Laundry Room. The clean and dirty sections of the Laundry Room are in the same room with no wall or functioning air system used to separate the two areas. When standing in the clean section of the room one could fully feel the air coming from the dirty section. Further observation of the Laundry Room, on 02/13/19 at 10:35 AM, revealed there were two wet mop heads along with a soiled towel lying on top of a barrel located in the clean section of the laundry room. There were also two (2) lift pads on the floor in the clean linens storage area. Laundry Aide (LA) #71 took the lift pads off the floor and placed them back on the clean storage shelf. The floors, sink, and washers/dryers were all soiled, sticky, and discolored. An interview with LA #71, on 02/13/19 at 10:40 AM, revealed she was not sure why the mop heads and towel were on top of the barrels. The LA stated she was not sure why the clean and dirty laundry areas did not have a barrier. The LA stated it would probably be a good idea to separate the two areas. The LA stated the laundry room could use a good cleaning. An interview with the Maintenance Director (MD), on 02/13/19 at 11:30 AM, revealed the Laundry Room's clean and dirty areas have been that way for at least twelve years. The MD stated he would ensure a barrier was instituted in the laundry room and would see that it was cleaned. The MD stated the Laundry Aide should not have put the lift pads that were on the floor back onto the clean storage shelf. b) Oxygen Supplies An observation of Resident #89, on 02/11/19 at 11:15 AM, revealed the Resident's nasal cannula and tubing was on the floor under the bed. An interview with Resident #89, on 02/11/19 at 11:16 AM, revealed her oxygen had been on the floor for a while. An interview with Director of Nursing (DON), on 02/11/19 at 11:25 AM, revealed the nasal cannula used for oxygen should never be on the floor. The DON removed the oxygen from the floor.",2020-09-01
1897,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2019-02-13,925,E,0,1,DR1J11,"Based on observation and staff interview, the facility failed to maintain an environment free from pests. Several resident hallways were observed to have gnats on multiple occasions. This practice affected two (2) of (4) resident hallways observed during the Long Term Care Survey Process (LTCSP). Hallway identifiers: 100 and 400 Hallways. Facility census: 99. Findings included: a) Observations Multiple observations during the LTCSP on 02/11/19, 02/12/19, and 02/13/19, revealed gnats on the 100 Hallway and the 400 Hallway. b) Interviews An interview with Licensed Practical Nurse (LPN) #76, on 02/13/19 at 8:25 AM, revealed the 400 Hallway has gnats occasionally. The LPN stated the gnats have been reported several times to her manager. An interview with the Maintenance Director (MD), on 02/13/19 at 11:30 AM, revealed there is not much to be done about gnats. He said because there is so much food in the facility that they will always be present. The MD stated the pest control company usually comes monthly to service the facility.",2020-09-01
1898,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2018-03-01,637,D,0,1,6GRG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a significant change comprehensive assessment in fourteen (14) days. Following an unwitnessed fall with a resulting fracture and a decline in activities of daily living (ADL) no evidence was found that a Minimum Data Set (MDS) was completed in the required fourteen (14) days. This was true for one (1) of twenty-one (21) residents reviewed for comprehensive assessment. Resident identifier: Resident #40. Facility census: 101. Findings include: a) Resident #40 Medical record review revealed Resident #40 unwitnessed fall with a resulting right [MEDICAL CONDITION] on 02/08/18. A review of the MDS with an Assessment Reference Date (ARD) revealed the resident required extensive assistance with toileting and bed mobility, and had no pain. An interview with Licensed Practical Nurse (LPN #155) on 02/27/18 at 3:00 PM, she stated there was a decline in the residents activities of daily living (ADLs) since the resident suffered a fracture. She further stated physical therapy ordered an abduction pillow to help stabilize the fracture but the resident refused to use the pillow. In addition, Roxinal ([MEDICATION NAME]) and [MEDICATION NAME] (pain) patch had been ordered to manage the residents' pain. An interview with the MDS Coordinator #28, on 02/27/18 at 4:18 PM revealed she agreed the significant change MDS was not completed in the required fourteen (14) days.",2020-09-01
1899,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2018-03-01,641,D,0,1,6GRG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to accurately complete the quarterly minimum data set (MDS) assessments for two (2) of twenty-one (21) reviewed assessments. The MDS for Resident #23 did not reflect the diagnoses of [MEDICAL CONDITION] reflux disease (GERD) or [MEDICAL CONDITION] and for Resident #51 there was no [DIAGNOSES REDACTED].#23 and #51. Facility census: 101. Findings included: a) Resident #23 A medical record review completed on 02/27/18 revealed the quarterly MDS with an assessment reference date (ARD) of 12/19/17 had no diagnoses [MEDICAL CONDITIONS] in Section I: Active Diagnoses for Resident # 23. Further investigation indicated this resident had received [MEDICATION NAME] 20 milligrams (mg) at bedtime [MEDICAL CONDITION] a start date of 06/16/16, she also received [MEDICATION NAME] 75 micrograms (mcg) at bedtime for [MEDICAL CONDITION] with a start date of 04/29/16. During a staff interview with the MDS Coordinator on 02/28/18 at 10:42 AM, she confirmed the quarterly MDS assessment did not include the diagnoses [MEDICAL CONDITIONS] in Section I: Active Diagnoses for Resident #23. b) Resident #51 A medical record review completed on 02/28/18 revealed the quarterly MDS with an assessment reference date (ARD) of 12/27/17 had no [DIAGNOSES REDACTED].# 51. Further investigation indicated this resident received [MEDICAL TREATMENT] services on Monday, Wednesday and Friday with a chair time of 10:30 AM. She was also taking [MEDICATION NAME] 2.4 gram (gm) two (2) times a day related to [MEDICAL CONDITION] with a start date of 12/13/17. During a staff interview with the MDS Coordinator on 02/28/18 at 3:20PM, she confirmed the quarterly MDS assessment did not include the [DIAGNOSES REDACTED].#51.",2020-09-01
1900,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2018-03-01,655,D,0,1,6GRG11,"Based on medical record reveiw and staff interview, the facility failed to provide a written copy of the baseline care plan to the resident and responsible party. This failed practice was found for two (2) of three (3) residents who were admitted after (MONTH) 28, (YEAR). Resident identifiers: #93 and #51. Facility census: 101. Findings include: a) Resident #93 and #52 A review of medical records show Residents #93 and #51, nor their responsible party, did not receive a written copy of the baseline care plan. In an interview with social worker on 03/01/18 at 9:05 AM she stated she had not given the written copy as required. There were sign in sheets to the care plan meeting but they were to show participation in the care plan process. This did not mean they were given a written copy of the baseline summary of the care plan.",2020-09-01
1901,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2018-03-01,657,D,0,1,6GRG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise a care plan when a resident experienced a fall with resulting [MEDICAL CONDITION]. Resident #40 experienced an unwitnessed fall resulting in a [MEDICAL CONDITION] with no changes or revisions made to the care plan. Resident identifier: #40. Facility census: 101. Findings included: a) Resident #40 A review of the medical record revealed Resident #40 experienced an unwitnessed fall resulting in a fractured right hip on 02/08/18. A review of the care plan revealed a focus initiated on 01/11/17 of --Falls: potential for injury from falls due to recent hospitalization for weakness, MI ([MEDICAL CONDITION] infarction - [MEDICAL CONDITION]), urinary tract infection [MEDICAL CONDITION]. Most recent fall on 01/30/18. Revised on 01/30/18. --Goal: Resident will have no major injury from falls, such as but not limited to fractures, head injury, or dislocations, through next review period. The goal was initiated on 01/11/17, revised on 01/23/17 with a target review date of 04/03/18. --Interventions: anti-roll backs to wheel chair, call light in reach, encourage to keep walker within reach, to wear non skid socks when ambulating or transferring, and scoop mattress. In addition a review of the Kardex (interventions for resident care) dated 02/27/18 noted toileting use independent with assistance of a walker and mobility transfer/ambulate independently with the assistance of a walker. The Kardex is generated from the care plan. An interview with Licensed Practical Nurse (LPN #155), on 02/27/18 at 3:00 PM, she stated the resident experienced a decline in activities of daily living (ADLs) since the right [MEDICAL CONDITION]. She further stated physical therapy ordered an abduction pillow to help stabilize the fracture but the resident refused to use the pillow. In addition, the physcian ordered Roxinal ([MEDICATION NAME]) and [MEDICATION NAME] (pain) patch to manage the residents' pain. When asked who was responsible for updating the care plan when there is a change in condition, LPN #155 stated, we (nurses) are. When asked if Resident #40's care plan had been revised to reflect the change if condition, she replied No.",2020-09-01
1902,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2018-03-01,676,D,0,1,6GRG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and medical record, the facility failed to ensure residents received timely assistance in getting hearing aid devices or repairs as needed. This was evident for one of one resident reviewed for hearing. Resident identifier: #93. Census: 101 Finding included: a) Resident #93 Observation during the initial tour on 02/26/18 revealed Resident #93 was wearing a hearing aid in the right ear. The resident states the hearing aid for the left ear did not work or needed a battery. Staff removed the hearing aid from the left ear, and went to see if there were batteries available. Medical record information showed the resident was identified as hard of hearing and had physician orders [REDACTED]. The minimum data set assessment identified hearing loss and she had hearing aids. Care plan intervention on the most recent MDS revealed hearing aids as ordered as an intervention. Record review found the nursing notes regarding the residents' hearing aids since 02/05/18 with no resolution. These notes were as follows: --02/22/18 - Hearing aids are broken. Does have one in ear. Son reported aide needed battery. --02/20/18 - Resident refused right hearing aid. --02/19/18 - Staff report hearing aids are not working at this time. --02/16/18 - Hearing aides are broken. --02/14/18 - Right hearing aide put in, can not locate left hearing aid. --02/12/18 - Resident refused hearing aid. --02/09/18 - Trying to get hearing aids to work. --02/08/18 - Hearing aids not working at this time. Will try to get batteries and get them to work before contacting MPO[NAME] --02/05/18 - Hearing aids are not working at this time. On 02/28/18 the facility provided documenation dated 02/27/18 (after surveyor intervention) with the hearing aid company in another state so they can send them for repair.",2020-09-01
1903,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2018-03-01,760,D,0,1,6GRG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, and the Centers of Disease Control (CDC) guidelines review, the facility failed to administer the Pneumococcal 13-valent Conjugate Vaccine (Prevnar 13) and the Pneumococcal Vaccine [MEDICATION NAME] ([MEDICATION NAME] 23) to Resident #40, in accordance to the physician's orders [REDACTED]. This practice had the potential to affect an isolated number of residents. Resident identifer: #40. Facility census: 101. Findings included: a) Resident #40 Record review found a verbal order from the physician for Resident #40 for: --Prevnar 13 Suspension, also known as Pneumococcal 13-Val Conj Vacc, inject 0.5 ml intramuscularly one time only for [MEDICATION NAME] until 01/22/18. --[MEDICATION NAME] 23 Injectable 25 mcg/0.5 ml, also known as Pneumococcal Vac [MEDICATION NAME], inject 0.5 ml intramuscularly one time only for [MEDICATION NAME] for 1 Day. Record review of the Medication Administration Record [REDACTED] --Prevnar 13 Suspension (Pneumococcal Vac [MEDICATION NAME]) Inject 0.5 ml intramuscularly one time only for [MEDICATION NAME] for 1 day with a start date of 01/22/18 at 1:30 PM. This medication was scheduled and administered on Monday, 01/22/18 1:44 PM. --[MEDICATION NAME] 23 Injectable 25 mcg/0.5 ml (Pneumococcal Vac [MEDICATION NAME]. Inject 0.5 ml intramuscularly one time only for [MEDICATION NAME] for 1 day with a start date of 01/22/18 at 1:30 PM. This medication was administered on 01/23/18 at 4:52 PM. Record review found the following nursing notes: --01/22/18 at 2:52PM - Staff Development Registered Nurse (RN) #164 noted [MEDICATION NAME] 23 was given intermuscularly in right deltoid. Temperature was 98.7. --01/23/18 at 7:18 PM - Licensed Practical Nurse (LPN) #14, noted resident was up on side of bed today and responsive to verbal stimuli. No adverse reactions noted from pneumovac vaccine. Oral temperature was 98.8 . Physician visited earlier with no new orders. No other problems or changes noted. No distress noted. --01/23/18 at 11:43 PM - LPN #165, LPN noted resident received Pneumonia injection on 01/23/18 with no adverse effects noted at this time. Oral Temperature was 98.0. No complaints of pain or discomfort verbalized or indicated this shift. Will continue to observe. --01/25/18 at 12:08 AM - LPN #165 noted resident received Pneumonia injection on 01/22/18 with no adverse effects noted at this time. Oral temperature was 97.9. No complaints of pain or discomfort verbalized or indicated this shift. No redness, swelling or pain at injection site. Will continue to observe. --01/25/18 at 2:04 PM - LPN #155 noted Pneumonia vaccine given on 01/22/18 with no signs or symptoms of adverse reactions noted. Resident temperate was 98.7. Will continue to observe. --01/26/18 at 11:59 AM - RN #90 noted resident had diarrhea once today. She denies nausea or abdominal discomfort. Temperatuve was 98.2. --01/26/18 02:08 PM - LPN #2 noted resident had Pneumonia vaccine on 01/22/18 and has had no signs or symptoms of an adverse reaction. Temperature was 98.7. Review of a Medication Error Report dated 02/01/18 (and as a result of surveyor intervention) the: --The facility failed to identify the significant medication error that occurred on 01/23/18, until 02/01/18. --The Director of Nursing (DON) #38 was not aware of the significant medication error that occurred on 01/23/18 until she was notified on 02/01/18 at 8:00 AM. --The DON failed to notify the physician of the significant medication error that occurred on 01/23/18, until 02/02/18 at 11:00 AM. --The facility failed to notify the Pharmacist of the significant medication error that occured on 01/23/18, until 02/28/18. --The significant medication error was not identified until 2/1/2018. --The facility documented the outcome to resident as no negative outcome to resident and Corrective action taken. --The facility documented observed resident-none further needed on the Medication Error Report. During an interview with DON #38, on 3/1/2018 at 8:05 AM, she revealed no one notified the physician immediately after [MEDICATION NAME] 23 was administered on 01/23/18, nor after the Prevnar 13 was administered, because there wasn't a negative outcome. When the DON was asked for a copy of the medication error report she replied, There's not a report. When the DON was asked for a copy of the investigation report of the medication error she replied, We didn't do an investigation. That person is no longer here. The facility failed to obtain documentation from the physician regarding this significant medication error until 03/01/18 at 08:55 AM.",2020-09-01
1904,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2018-03-01,842,D,0,1,6GRG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure resident medical records were complete and accurate. A dose of [MEDICATION NAME] sulfate was documented incorrectly on the Medication Administration Record [REDACTED]. This was true for one (1) of 21 records reviewed. Resident identifier: #67. Facility census: 101. Findings included: a) Resident #67 Medical record review revealed Resident #67 had a fall in the shower on 02/2018 with a resulting fratured femur (leg bone). After consultation with the physician and the MPOA, the decision was made not to surgically repair the fracture and provide comfort measures and for the resident to remain in the facility. [MEDICATION NAME] sulfate (MS) 0.25 milliliters (mls) by mouth was ordered on [DATE] by the attending physician. The MS was to be given every two (2) hours as needed for pain. A review of Nurses Notes revealed on 02/22/18 at 1704 (5:04 PM) Resident #67 was given 0.25 mls of MS. An addition dose was documented at 19:35 (7:35 PM). A review of the MAR indicated [REDACTED]. A review of the narcotic sheet revealed the resident received two (2) does of MS rather than one (1) dose of .25 mls and 1 ml. An interview with the Director of Nursing (DON) on 03/01/18 at 11:05 AM revealed agreement that the MS had been documented in error. In addition, a review of the nurses noted on 02/22/18 at 19:35 (7:35 PM) stated Resident moaning. [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg given sublingual (under tongue) as ordered. Resident incontinent of stool and incontinent care given by staff. I the nurse was called into observe her. Resident at that time had abdominal respirations and skin was mottled (blue) from chest to feet. upper extremities were warm to touch. When I spoke her name she partially opened her eyes. The nurses note was signed by Licensed Practical Nurse (LPN) #2. A continuing review of the nurses notes revealed on 02/22/18 at 2100 (9:00 PM) This Nurse went to check Residents status and found at this time had no pulse and chest auscultation revealed no heartbeat. Death of resident verified per second Nurse. Physician (name) notified of resident death and family member (name) POA was notified of her death. POA verified resident is to be sent to funeral home (name). The nurses note was signed by LPN #2. No other evidence could be found that the MPOA had been notified when the resident was actively dying at &:35 PM. In an interview with the Assistant Director of Nursing (ADON) on 03/01/18 at 12:55 PM revealed she remembered the MPOA had come to the facility but agreed there was no evidence in the medical record that the MPOA had been in the facility. She stated she remembered the MPOA left about an hour prior to the death of Resident #67. When asked if her expectations of the staff were to document evidence of this visit in the medical record, she did not reply. An additional interview with the DON at 11:05 AM on 03/01/18 , revealed when ask if she would expect her staff to monitor a resident more closely and the MPOA to be notified when the resident was mottled and actively dying, she stated you know you have to give your medications in the real nursing world pointing to the nurses notes at 9:00 PM.",2020-09-01
1905,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2018-03-01,883,D,0,1,6GRG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, the Centers of Disease Control (CDC) guidelines, record review, staff interview and family interview, the facility failed to provide education regarding the benefits and potential side effects of pneumococcal immunizations and obtain consent prior to Resident #40's Medical Power of Attorney (MPOA) prior to administering Pneumococcal 13-valent Conjugate Vaccine, also known as Prevnar 13, in addition to Pneumococcal Vaccine Polyvent, also known as [MEDICATION NAME] 23. This failed practice had the potential to affect an isolated number of residents. Resident identifier: #40. Facility census: 101. Findings included: a) Resident #40 1. Facility policy Policy review found the facility's Pneumococcal Vaccine (Series), Date Implemented 11/28/17, Policy: It is our policy to offer our residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. Policy Explanation and Compliance Guidelines: --Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. --Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization. --The individual receiving the immunization, or the resident representative, will be provided with a copy of CDC's current vaccine information statement relative to that vaccine. --If necessary, the vaccine information statement will be supplemented with visual presentation or oral explanations to assist vaccine recipients in understanding. --The type of pneumococcal [MEDICATION NAME] vaccination (PCV13, PPSV23/PPSV) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations. --A series of vaccinations will be offered to immunocompetent adults greater than or equal to 65, depending on current vaccination status and practitioner recommendations: --No previous vaccination (or vaccination status is unknown): PCV13 first, the PPSV23 one year later. --The resident's medical record shall include documentation that indicates at a minimum, the following potential side effects of pneumococcal immunization. 2. Verbal physician orders [REDACTED]. Record review found a verbal order from the physician on 01/22/18 for [MEDICATION NAME] 23 (PPSV23) Injectable 25 mcg/0.5 ml, also known as Pneumococcal Vac [MEDICATION NAME], inject 0.5 ml intramuscularly one time only for [MEDICATION NAME] for 1 Day. 3. Informed consent Record review of Pneumococcal Vaccination Informed Consent, the facility's registered nurses failed to document permission was obtained for the facility to administer the Pneumococcal vaccination(s) per CDC guidelines, and/or if the resident had or had not received the pneumococcal vaccinations. Additionally, the facility's registered nurses failed to document they educated the resident's representative on the vaccine(s) via the Pneumococcal Vaccine Information Statement(s) (VIS) from the CDC. Lastly, the facility's registered nurses documented the Verbal Consent was obtained on 01/18/18; however, the physician's orders [REDACTED]. 4. Interviews A telephone interview completed on 03/01/18 at 10:45 AM, with the Medical Power of Attorney (MPOA) for Resident #40, she stated, I did receive a call from the facility, from two (2) nurses, asking permission to administer the flu vaccine to my mother. When questioned if the nurses provided verbal explanation and education regarding the two (2) Pneumonia Vaccines prescribed for her mother, she replied, Two vaccines? The nurses did not tell me that my mother would be receiving two pneumonia vaccines. They didn't even explain or educate me on the only vaccine I thought they were going to administer to my mother. Now I did receive a paper in the mail after that, and right now, I can't even remember what that paper was about. When asked about the medication error the MPOA stated, No! I didn't even know she was getting two pneumonia vaccines, and they never notified me of a medication error! What happened? It was explained that based on her mother's medical record review, a nurse administered the pneumococcal vaccine, Prevnar13 (PCV13) on Monday, 01/22/18 and on Tuesday, 01/23/18, the pneumococcal vaccine 23 (PPSV23) was erroneously administered. She asked how these two vaccines should been administered, and it was explained to her that according to the Centers for Disease Control (CDC) guidelines, as well as the facility's policy, the pneumococcal vaccine13 is to be administered first, and the pneumococcal vaccine 23 is to be administered at least one (1) year later. She replied, No. No one informed me of this. The facility failed to provide education and obtain consent prior to administering pneumococcal immunization.",2020-09-01
1906,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2018-06-13,641,D,1,0,YQFI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to accurately assess the resident for the use of antidepressant medication. This was evident for one (1) of ten (10) residents in the sample who had minimum data set (MDS) assessments evaluated during the investigation. Resident identifier #2. Facility census: 108. Findings included: a) Resident #2 A review on 06/12/18 of the quarterly MDS dated [DATE] revealed the resident was receiving antidepressant medications seven (7) days a week. This was also identified on the previous MDS of 02/20/18. The [DIAGNOSES REDACTED]. Interview of the MDS coordinator on 06/11/18 at 12:15 p.m. indicated the [DIAGNOSES REDACTED]. This list is where the MDS pulls information from to show it is a current condition. In a review of other information in the medical record, there was an entry from the social worker on 02/20/18 which stated the resident has a [DIAGNOSES REDACTED]. Additionally, there were current physician orders [REDACTED]. This practice did not show the MDS quarterly assessment had a rationale for the use of antidepressant medication.",2020-09-01
1907,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2018-06-13,656,E,1,0,YQFI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to develop a comprehensive person-centered care plan for each resident, consistent with the resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Resident #10, #29, #85 and #96 care plans failed to identify specific orders for speech, physical and occupational therapies. This was true for four (4) residents medical records reviewed during the complaint process. Resident identifiers: #10. #29, #85, and #96. Facility census: 108. Findings included: a) Resident #10 A review of the medical record for Resident #10 on 06/12/18 revealed the comprehensive person-centered care plan was not developed to include measurable objectives and timeframes to meet this resident's rehabilitation services for speech therapy (ST), physical therapy (PT) and occupational therapy (OT). The physician orders [REDACTED]. Start date: 05/28/18 and end date of 06/25/18. PT clarification: orders for therapeutic activity, gait training for eight (8) weeks five (5) times a week. Start date: 05/26/18 and ST clarification: ST five (5) times a week for four (4) weeks to address cognitive deficits with poor safety awareness. Start date: 05/28/18 and end date: 06/25/18. During an interview with the director of nursing (DON) on 06/12/18 at 3:30 PM, verified the care plan for Resident #10 did not identify specific orders as related to OT, PT, and ST. b) Resident #29 A review of the medical record for Resident #29 on 06/11/18 revealed the comprehensive person-centered care plan was not developed to include measurable objectives and timeframes to meet this resident's rehabilitation services for OT. The physician orders [REDACTED]. Start date: 06/10/18. During an interview with the DON on 06/12/18 at 3:30 PM, verified the care plan for Resident #29 did not identify specific orders for OT. c) Resident #85 A review of the medical record for Resident #85 on 06/12/18 revealed the comprehensive person-centered care plan was not developed to include measurable objective and timeframes to meet this residents rehabilitation services for OT and PT. The physician orders [REDACTED]. Start date: 05/24/18. PT clarification: order for self care therapeutic activities, biofreeze as needed, diathermy for eight (8) weeks five (5) times a week. Start date: 05/24/18. During an interview with the DON on 06/12/18 at 3:30 PM, verified the care plan for Resident #85 did not identify specific orders for OT and PT. d) Resident #96 A review of the medical record for Resident #96 on 06/12/18 revealed the comprehensive person-centered care plan was not developed to include measurable objectives and time frames to meet the resident's rehabilitation services of OT and PT. The physician orders [REDACTED]. Start date: 06/06/18 and end date: 07/04/18. PT clarification: orders for therapeutic exercises and activities, gait training, diathermy for four (4) times a week for 5 weeks. Start date: 06/06/18 and end date: 07/04/18. During an interview with the DON on 06/12/18 at 3:30 PM, verified the care plan for Resident #96 did not identify specific orders for OT and PT.",2020-09-01
1908,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2018-06-13,684,D,1,0,YQFI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to provide the needed care and services in accordance with professional standards of practice to meet the needs of a resident. A physician's orders [REDACTED]. Resident #110 did not receive antibiotics for a urinary tract infection. This was found for one (1) of three (3) records reviewed. Resident identifier: #110. Facility census: 108. Findings included: a) Resident #110 Review of the medical record on 06/11/18, revealed Resident #110 was admitted to the facility on [DATE] at 2:42 PM. A faxed copy of urine culture results from the referring hospital dated 04/12/18 was found in the closed medical record under the section titled Lab & Special Reports. The lab form identifies a urine culture drawn on 04/11/18, positive for [DIAGNOSES REDACTED] pneumonia on 04/12/18 at 11:19 AM. The top of the faxed report contains a hand written note stating: Bactrim DS (double strength) BID (twice a day) x (times) 7 days. signed by Dr. #134 and dated 04/12/18. The fax sheet lacks identifying information related to who received this urinalysis culture result. The physician orders [REDACTED]. The medical record and faxed lab form were reviewed by the Director of Nursing (DON) during an interview on 06/12/18 at 11:12 PM. The DON reported she was unaware of the urinary culture result for Resident #110 and stated she could not identify where the fax came from. The DON confirmed the signature on the faxed lab report belonged to Dr. #134 and acknowledged Resident #110 never received the antibiotic prior to her transfer out of the facility on 04/14/18.",2020-09-01
1909,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2019-08-27,880,E,1,0,YQIM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview and policy review, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections to the extent over which it had control. Resident (#1), in contact precautions related to a contagious gastrointestinal illness, had no signage at the door to direct family or visitors as to the precautions necessary before entering the room. Staff failed to utilize personal protective equipment while in direct contact with environmental objects in the rooms Resident #2 and #3 who were in contact precaution isolation for a contagious gastrointestinal illness. Staff failed to wash hands with antimicrobial soap after providing service to a resident (#2) who was in contact precautions isolation. This had the potential to affect more than a limited number of residents. Resident identifiers: #1, #2, #3. Facility census: 110. Findings included: a) Resident #1 Observation on 08/26/19 at 9:30 AM found Resident #1 resided in a room by himself. A plastic receptacle which held disposable gloves, gowns, and masks hung on the outside of his door. There was no signage at the door to see the nurse before entering the room, and/or the type of isolation ordered, and/or personal protective equipment required before entering the room. Medical record review on 08/26/19 revealed this resident was ordered contact precautions due to a contagious gastrointestinal illness. The administrator on 08/26/19 at 2 PM provided a copy of the facility's policy on infection reporting which stated, in part, that transmission-based isolation precautions will be noted with a sign on the resident's door for the duration the resident is on isolation. He agreed that visitors should be made aware of the presence of isolation for their resident, and educated on the types of personal protective equipment and appropriate handwashing needed so as not to spread pathogens during or after their visits. Observation on 08/26/19 at 3 PM found there was still no signage at the resident's door. An interview was conducted with licensed nurse #5 (LPN #5) on 08/26/19 at 3:05 PM. She said he was supposed to have a sign posted on his door to see the nurse for instructions before entering the room. She surmised that perhaps the sign fell off the door and someone picked it up off the floor and did not replace it. Nursing assistant #6 (NA #6) then obtained a sign to see the nurse for instructions before entering the room. She posted the sign on the resident's door. An interview was conducted with the director of nursing (DON) on 08/26/19 at 4 PM. She said staff told her about the incident where Resident #1 had no signage at his door. She acknowledged that he was in contact precautions, and should have had a sign posted on his door to see the nurse for instructions before entering the room. She said disposable gloves and gown were required for contact with this resident or his environment. b) Resident #2 Review of the medical record on 08/26/19 revealed this resident was ordered contact precautions due to a contagious gastrointestinal illness. Observation on 08/27/19 at 12:25 PM found nursing assistant #10 (NA #10) in Resident #2's room. A plastic receptacle which held disposable gloves, gowns, and masks hung on the outside of his door. NA #10 had just brought the resident's lunch to him. Resident #2 lay in bed with the head of his bed elevated in a position in which to eat his lunch. His meal sat on his overbed tray which was across his lap. NA #10 was observed standing beside his bed while they conversed, with her uniform in direct contact with the resident's bed linens. She wore no disposable gown or gloves. NA #10 left his room without washing her hands. She walked up the hall and obtained some alcohol-based hand sanitizer from a wall-mounted dispenser to cleanse her hands. She then walked to the food cart to obtain a tray for another resident. Upon inquiry as to whether she wore disposable gloves or gown in Resident #2's room just now, she replied in the negative. Upon inquiry if she had washed her hands with antimicrobial soap and water before leaving the room, she replied in the negative. She asked Was I supposed to?Informed her that alcohol-based hand sanitizer will not kill spores. She then went returned to his room and washed her hands. The administrator on 08/27/19 provided a copy of the facility's policy on standard precautions which directed in part to wash hands with antimicrobial soap and water if contact with spores (e.g. [DIAGNOSES REDACTED]icile and some others named) is likely to have occurred. It noted the physical action of washing and rinsing hands under such circumstances is recommended because alcohols, [MEDICATION NAME], and other antiseptic agents have poor activity against spores. The administrator provided a copy of the facility's policy on transmission based precautions which directed personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination such as [MEDICAL CONDITION], noroviruses, and other intestinal tract pathogens. c) Resident #3 Review of the medical record on 08/26/19 revealed this resident was ordered contact precautions due to a contagious gastrointestinal illness. Observation on 08/27/19 at 12:30 PM found nursing assistant #20 (NA #20) in Resident #3's room. A plastic receptacle which held disposable gloves, gowns, and masks hung on the outside of his door. NA #20 had just brought in the resident's lunch. She removed her disposable gloves, then sat in a chair directly beside the resident's bed as she prepared to feed him his meal. She wore no disposable gown. She wore no gloves at this time. An interview was conducted with licensed nurse #7 (LPN #7) on 08/27/19 at 12:31 PM. She was informed that NA #20 sat in a chair beside Resident #3's bed to assist with feeding him, and she wore no gloves or gown. LPN #7 said the nursing assistant should have donned personal protective equipment. She said she would intervene. d) An interview was conducted with the administrator and the director of nursing (DON) on 08/27/19 at 12:40 PM. They said NA #10 should have worn gloves and gown while she was in Resident #2's room. They said she should have washed her hands with antimicrobial soap and water before she left his room, as alcohol-based hand sanitizer alone will not kill spores. The DON said ideally a staff person should have been in the resident's room while wearing a disposable gown and gloves, and received his meal from another staff person in the hallway handing it in to the gowned and gloved staff person. The administrator and the DON said NA #20 should have donned personal protective equipment consisting of disposable gown and gloves while she provided care to Resident #3 and came in direct contact with the resident and with inanimate objects in his room which could spread pathogens. The administrator showed an inservice attendance roster where NA #10 and NA #20 signed that they attended an inservice in proper handwashing and contact precautions related to the gastrointestinal illness which Resident #2 and Resident #3 were currently experiencing. The administrator provided a copy of the facility policy on isolation precautions which stated, in part, that contact precautions are measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. The administrator provided a copy of the facility Infection Prevention and Control Program policy with stated, in part, that a resident with an infection or communicable disease shall be placed on isolation precautions as recommended by current Centers for Disease Control and Prevention (CDC) Guidelines for Isolation Precautions.",2020-09-01
1910,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2019-10-30,684,D,1,0,E24Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to obtain neurological assessments following a resident's fall, and failed to assess pulse oximetry oxygen levels timely on a resident with a change in condition. This was evident for one (1) of three (3) sampled residents reviewed for falls and safety. Resident identifier: #6. Facility census: 111. Findings included: a) Resident #6 The medical record was reviewed on 10/29/19. This capacitated resident was hospitalized prior to admission with [MEDICAL CONDITION] and the need for mechanical ventilation. The discharge summary narrative from (name of hospital) included that Due to patient noncompliance with [MEDICAL CONDITION], patents hypercarbia continued to worsen and she was transferred to the (intensive care) unit .upon arrival to (intensive care) unit, patient was intubated . This resident experienced an unwitnessed fall from bed on 09/18/19 at 11:35 PM. The nurse notified the resident's physician of the fall, and began neurological assessments. A nurse progress note dated 09/19/19 at 12:31 AM conveyed the nurse assessment of a change in condition as evidenced by the resident not responding to staff and very hard to arouse. The blood pressure was 94/58, pulse rate 104 beats per minute, and respiratory rate of 20 breaths per minute. There was no evidence that the resident's oxygen level per pulse oximetry was obtained. The nurse called the physician who gave orders to reapply her [MEDICAL CONDITION] and reassess in fifteen (15) minutes; if no improvement, send her to the emergency room (ER) for observation. A nurse progress note dated 09/19/19 at 12:38 AM conveyed this resident was reassessed after [MEDICAL CONDITION] was reapplied, and the resident was then easily aroused and communicating with staff. Again, there was no evidence that the resident's oxygen level per pulse oximetry was obtained. Review of the neurological assessment flow sheet of 09/18/19 through 09/19/19 found written directives to obtain neurological assessments every fifteen (15) minutes for four (4) consecutive times, then every 30 minutes. The neurological assessment flow sheet contained evidence of her level of consciousness, pupil response, motor function, and pain assessment only once on 09/18/19 at 11:35 PM. There was no evidence of this assessment at 11:50 PM, 12:05 AM, 12:20 AM, 12:50 AM, 1:20 AM, and 1:50 AM. There was no evidence of blood pressure and pulse assessments at 12:20 AM, 1:20 AM, and 1:50 AM. A nurse progress note dated 09/19/19 at 1:48 AM conveyed this resident was sent to the ER due to altered mental status and oxygen saturation of 73% with Bi-PAP. An oxygen level of 73% is indicative of acute [MEDICAL CONDITION]. An interview was conducted with the director of nursing (DON) on 10/29/19 at 3:00 PM. She said she did not see evidence that the resident's oxygen level was assessed after the fall at 11:35 PM until she was sent to the ER at 1:48 AM. She agreed there was no way to know what her her oxygen level was from the time of the fall at 11:35 AM until she was sent to the ER at 1:48 PM. She said the most recent pulse oximetry assessment prior to the fall was at 93% on room air on 09/18/19 at 9:21 PM. The DON agreed there were three (3) omissions of blood pressure and pulse assessments and two (2) omissions of the respiratory rate assessments from the time of the fall until sent to the ER at 1:48 AM She said there was evidence only once after the fall that the level of consciousness, pupil response, motor function, and pain were assessed as directed, and six (6) times it was omitted. She said it's no excuse, but the staff was probably so busy working with her that they may have forgotten to record the neurological assessments. On 10/30/19 at 1:30 PM the administrator provided a copy of their policy on neurological assessment. This policy's implementation date was 03/27/18. It states in part the following: -Neurological assessment are indicated following an unwitnessed fall. - When assessing neurological status, always include frequent vital signs. - Any change in vial signs or neurological status in a previously stable resident should be reported to the physician immediately. The administrator said most of their forms are electronic, but the neurological assessment flow sheet is hard copy which must be hand-written. He said the flow sheet could be incorporated to include a place in which to record the oxygen level assessments per pulse oximetry. He said this might serve as a reminder to staff when dealing with residents with respiratory problems.",2020-09-01
1911,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2019-10-30,883,D,1,0,E24Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview, and policy review, the facility failed to ensure it assessed for and/or offered pneumococcal vaccinations timely after admission. This was evident for one (1) of three (3) sampled residents. Resident identifier: #4. Facility census: 111. Findings included: a) Resident #4 Review of the medical record on 10/29/19 found this resident first came to the facility in (MONTH) 2019. Admission [DIAGNOSES REDACTED]. On 09/27/19 the resident signed consent to accept a pneumococcal vaccination. Review of physician's orders [REDACTED]. An interview was conducted with the director of nursing (DON) on 10/29/19 at 4:30 PM. Upon inquiry as to whether the facility conducted a pneumococcal immunization history for this resident, she said she would try and find out. Medical record review on 10/30/19 found the nurse practitioner ordered a Prevnar 13 pneumococcal vaccination. A new order on the (MONTH) MAR indicated [REDACTED]. An interview was conducted with the administrator on 10/30/19 at 1:00 PM. He said they realized that consents for pneumococcal vaccination on recent new admissions were being obtained. However, the next step to get those vaccinations ordered was not followed through. He said this was a glitch that they have now corrected. He said they held a Quality Assurance and Performance Improvement (QAPI) this morning and developed steps to ensure that all new admissions receive their pneumococcal vaccines if they consent and it is not contraindicated. Also, they are catching up today to identify any recent new admissions whose pneumococcal vaccinations were consented but then inadvertently omitted. The administrator provided a copy of their pneumococcal vaccination policy and procedure. It stated as follows: - Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, will be offered the vaccination unless medically contraindicated or the resident has already been vaccinated. - Assessments of pneumococcal vaccination status wilt be conducted within five (5) working days of the resident's admission if not conducted prior to admission. - Pneumococcal vaccinations will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol. - Administration of the pneumococcal vaccination or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.",2020-09-01
1912,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-12-16,241,D,0,1,R3ET11,"Based on observation and staff interviews, the facility failed to ensure a resident was treated with dignity and respect during the provision of pericare/catheter care. This was true for one (1) of two (2) residents reviewed in Stage 2 of the Quality Indicator Survey (QIS) for urinary catheter use. Dignity and respect was not ensured for Resident #149 while receiving pericare/catheter care in regards to privacy curtains not being closed and staff entering the resident's room without verifying permission to enter room. This practiced had the potential to affect more than a limited number of residents. Resident identifier: #149. Facility census: 90. Findings include: a) Resident #149 On 12/15/16 at 9:07 a.m., the provision of pericare/catheter care for Resident #149, by Nurse Aide (NA) #104 and NA #56 was observed. Observations revealed NA#104 and NA #56 did not pull the bedside privacy curtain closed around the resident's bed prior to providing care. While care was being provided NA #2 knocked on the door, and proceeded swiftly to enter the room, without anyone granting permission to enter. At the time NA#2 opened the door, the resident's perineal area was exposed to anyone that may have been in the hallway. Interview with NA#2, NA#104, and NA#56, after pericare/catheter care was given, revealed all NAs had been instructed to knock on resident's door and wait for permission before entering. NA#104 and NA#56 agreed the privacy curtain should have been pulled all around the resident's bed before starting care to ensure the privacy of the resident.",2020-09-01
1913,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-12-16,272,D,0,1,R3ET11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure an accurate comprehensive assessment for Resident #74 who sustained a fall with injury, and for Resident #44's dental condition. This affected two (2) of twenty-one (21) Stage II sampled residents. Resident identifiers: #74, #44. Facility census: 90. Findings include: a) Resident #74 Review of the medical record on 12/15/16, found this resident sustained [REDACTED]. He received multiple scrapes to the left knee. Upon return to the facility, nursing staff notified the physician of the accident. The physician ordered x-rays of the left knee. The x-ray report showed no fracture or dislocation of the left knee. Later, the resident was discharged to the hospital, and returned to the facility on [DATE]. The five (5) day minimum data set (MDS), with assessment reference date (ARD) of 11/23/16, incorrectly assessed he had sustained no falls, and no falls with injury, in the past two (2) to six (6) months prior to the re-entry date of 11/18/16. An interview was conducted with MDS nurse #133 on 12/15/16 at 12:00 p.m. She reviewed the nurse progress notes. She acknowledged he sustained a fall on 07/18/16 while out with his family. She said the five (5) day MDS with ARD 11/23/16 was coded incorrectly as having had no falls in the past two (2) to six (6) months prior to re-entry, and coded incorrectly has having had no falls with injury in the past two (2) to six (6) months prior to re-entry. b) Resident #44 Observation on 12/13/16 at 9:54 a.m. found this resident's upper gum contained numerous broken teeth. She denied pain at this time. Review of the medical record on 12/14/16 found the five (5) day admission minimum data set (MDS), with assessment reference date (ARD) of 03/03/16, assessed she had no dental issues. The assessment question as to whether the resident had broken natural teeth, was answered incorrectly as no. Review of a nurse progress note dated 03/21/16 found it addressed this resident had an appointment scheduled with (name of dentist) on 04/07/16 at 2:30 p.m. for a consultation for teeth extractions. Review of the physician's progress note dated 04/26/16 included a follow-up note for her history of dental decay. Her physician stated, She is scheduled for tooth extraction in May. Her daughter wanted to make certain that her pain was covered. She does have intermittent pain, but nothing on a regular basis. The physician's assessment/plan stated, 1. Dental decay. I placed her on scheduled doses of extra strength Tylenol to minimize any potential adverse effects. A telephone interview was completed with the resident's power of attorney on 12/14/16 at 7:00 p.m. Upon inquiry, she said this resident had broken teeth on the upper level that was present before she first arrived at the facility. She said prior to admission to the facility, this resident had an appointment scheduled with a dentist for extraction of five (5) broken teeth on the upper gum, and plans to make an upper denture. However, the resident sustained [REDACTED]. On 12/15/16 at 8:00 a.m., an interview was conducted with minimum data set (MDS) nurse #36. She said the nurse who completed the MDS admission assessment for this resident no longer works at this facility. MDS nurse #36 said she always meets the resident face to face, in addition to reviewing the medical record, before completing the MDS. She reviewed this resident's admission MDS, with ARD of 03/03/16, which assessed the resident had no dental issues. She then read nurse progress notes and physician's progress notes, which stated otherwise. MDS nurse #36 agreed the MDS admission assessment was inaccurate related to the dental assessment. She acknowledged that since the care area assessment (CAA) of dental did not trigger, it therefore would not have been included in the resident's care plan.",2020-09-01
1914,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-12-16,279,D,0,1,R3ET11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a care plan with measurable goals and interventions to ensure provision of care to meet range of motion needs of Resident #24, who had contractures in the upper body and hands. This was evident for one (1) of two (2) residents reviewed for range of motion, and out of twenty-one (21) Stage II sampled residents. Resident identifier: #24. Facility census: 90. Findings include: a) Resident #24 Review of the medical record on 12/14/16 revealed pertinent [DIAGNOSES REDACTED]. Review of the annual minimum data set (MDS) with assessment reference date (ARD) of 09/09/16, assessed she had contractures in both hands, one (1) shoulder, and both knees. An interview was conducted with physical therapist #127, on 12/14/16 at 3:10 p.m. She said currently this resident is listed with therapy as having left hand and left shoulder and right pinkie finger contractures. She said the 09/09/16 MDS which identified contractures of both knees was probably correct at that time. She said physical therapy (PT) picked her up again in (MONTH) which resulted in some improvements in the functionality of her knees. Per the PT discharge assessment dated [DATE], this resident no longer met the definition for knee contractures. Physical therapist #127 said this resident most recently received occupational therapy (OT) for upper body and bilateral upper extremities in (MONTH) (YEAR). She said OT recommended range of motion (ROM) per restorative nursing services to her bilateral hands and shoulders upon discharge from OT in (MONTH) (YEAR). She explained that OT treats the upper body, and PT treats the lower body in this setting. Physical therapist #127 said when this resident's most recent PT service ended on 09/20/16, they referred her to restorative nursing services for maintenance of the lower extremities and for ambulation. An interview was then conducted with restorative nurse #38 on 12/14/16 at 3:20 p.m. She said restorative has this resident for lower extremity ROM and ambulation three (3) to six (6) times per week. She said restorative is not currently performing ROM to the bilateral upper extremities which would include the hands and shoulders, nor have they had her this year for upper body restorative services. On 12/14/16 at 3:30 p.m. restorative nurse #38 spoke with physical therapist #127 by telephone. She relayed that restorative only has this resident for ambulation and for ROM to the lower extremities. A second interview was conducted with physical therapist #127 on 12/14/16 at 4:00 p.m. She provided a copy of the OT discharge summary dated 02/09/16, which stated the patient is refusing orthotic device but will continue on ROM restorative for bilateral hands and for bilateral shoulder flexion program. The resident was discharged from OT to the long-term care facility with a ROM program to facilitate the resident maintaining her current level of performance, and to prevent decline. The OT discharge summary also stated that development of, and instruction in the following Restorative Nursing Program has been completed with the interdisciplinary team: ROM (active) and ROM (passive). Upon inquiry as to when she was most recently screened by therapy, #127 said she was most recently screened as part of her quarterly assessment on 11/30/16. She said at that time, there were no changes per patient or staff related to her activities of daily living or to her functionality, and there were no changes in the contractures. Physical therapist #127 said this resident needs range of motion to her hands and shoulders, and that somehow this got lost in the shuffle. An interview was completed with the administrator on 12/14/16 at 4:30 p.m. She acknowledged the concern with the resident having no range of motion services to the upper body and upper extremities since February, (YEAR). On 12/14/16 at 4:30 p.m., the director of nursing provided a copy of the resident's current care plan. Review of this care plan found that nowhere in the care plan were her contractures of the upper extremities identified, or any goals or interventions developed to prevent further decline in functionality of the upper extremities. Instead, the care plan contained a focus for restorative services for ambulation and bilateral lower extremity range of motion to promote mobility and joint movement. On 12/15/16 at 9:00 a.m. the administrator was informed of the lack of care planning for the contractures of this resident's upper body/extremities. No further information was provided prior to exit.",2020-09-01
1915,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-12-16,280,D,0,1,R3ET11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to revise the care plan for one (1) of twenty-one (21) residents reviewed. Resident #63's care plan was not revised to reflect the resident's status regarding a fall. Resident identifier: #63. Facility census: 90. Findings include: a) Resident #63 Record review reveals Resident #63 fell on [DATE] causing injury to the head. The resident was then sent out of the facility for a computerized tomograpy (CT) scan of the head, with negative results. The current care plan revealed a problem of risk for falls with no update of an actual fall. On 12/14/16 at 10:18 a.m., registered nurse #133 reviewed the medical records and agreed the care plan had not been revised to include the actual fall.",2020-09-01
1916,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-12-16,309,D,0,1,R3ET11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and pharmacy interview, the facility failed to follow physician's orders for a resident prescribed a steroidal inhaler (Symbiocort). A nurse failed to instruct or offer Resident #45 the opportunity to rinse his mouth and spit out any residue following the inhalation of a steroidal medication. A nurse also failed to administer the correct dose of [MEDICATION NAME] (stool softener) for Resident #145. These errors affected three (2) of seven (7) residents observed during medication pass. Resident identifiers: #145, #45. Facility census: 90. Findings include: a) Resident #145 During observation of a medication administration on 12/14/16 at at 8:03 a.m., licensed practical nurse #114 gave two (2) tablets of [MEDICATION NAME] 50 milligrams/Senna 8.6 milligrams to Resident #145. This amounted to 100 milligrams (mg) of [MEDICATION NAME]. The nurse obtained the medication from a bottle of stock medications kept in the top drawer of the medication cart. Review of physician's orders on 12/14/16 at 9:20 a.m. found physician's orders were actually for two (2) [MEDICATION NAME] 100 milligram tablets (without Senna) twice per day to prevent constipation. This amounted to 200 mg. of [MEDICATION NAME]. This information was relayed to nurse #114 at this time. She said she would obtain a stock bottle of plain [MEDICATION NAME] for the medication cart. On 12/15/16 at 9:00 a.m., the administrator was informed of the medication error rate greater than five (5) per cent, and the details of those errors. b) Resident #45 During observation of a medication administration on 12/14/16 at 8:13 a.m., licensed practical nurse #34 administered Symbiocort via a hand-held aerosol to Resident #45. The nurse did not offer the resident a cup of water to rinse his mouth and spit after using this inhaler which contained a steroid. The resident said, when asked specifically, that he sometimes rinses his mouth after using the Symbiocort, but only if the nurse brings him a cup and lets him rinse his mouth and spit at the bedside. He explained that he is unable to get out of bed by himself to go to the sink. Review of the physician's orders on 12/14/16 at 9:30 a.m. found directives to inhale two (2) puffs of Symbiocort Aerosol 80-4.5 micrograms orally two (2) times per due day. It contained further directives to rinse the mouth with water after administration and DO not swallow the rinse water. An interview was conducted with the consultant pharmacist on 12/14/16 at 3:00 p.m. She said the nurses are supposed to have the residents rinse their mouths and spit after any inhaled medication with steroids such as Symbiocort. She said that according to the manufacturer's instructions, failure to rinse the mouth and spit the rinse water after administration of this medication could result in [MEDICAL CONDITION](yeast, or thrush). Facility consultant #132 was present during this telephone interview. On 12/15/16 at 9:00 a.m. the administrator was informed of the medication error rate greater than five (5) per cent, and the details of those errors.",2020-09-01
1917,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-12-16,318,D,0,1,R3ET11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure a resident with a limited range of motion in the bilateral upper extremities received restorative services to prevent potential further decrease in range of motion of the upper extremities. This affected one (1) of two (2) residents reviewed for range of motion, out of twenty-one (21) Stage II sampled residents. Resident Identifier: #24. Facility census: 90. Findings include: a) Resident #24 Observation of Resident #24 on 12/13/16 at 10:22 a.m. found her sitting in a wheelchair. She showed she was unable to straighten several fingers of her hands. She had no splints in place. Medical record review on 12/14/16 revealed pertinent [DIAGNOSES REDACTED]. An interview was conducted with physical therapist #127 on 12/14/16 at 3:10 p.m. She said currently this resident is listed with therapy as having left hand and left shoulder and right pinkie finger contractures. She explained physical therapy (PT) primarily works with the resident on the lower body and lower extremities, and occupational therapy (OT) works with the resident's upper body and upper extremities. She said left hand contractures are for the two (2) fingers on the left hand. She said at the last OT evaluation in February, (YEAR), OT had goals for the two (2) fingers of the left hand and noted the resident refused orthotic devices. OT did, however, recommend range of motion restorative services to the bilateral hands and shoulders upon discharge from OT in February, (YEAR). She said she has had no further OT services since then. She explained that this resident no longer met the definition for a knee contracture, per PT assessment dated [DATE]. She said her most recent PT services were in (MONTH) (YEAR) for bilateral lower extremity exercises and ambulation with a front-wheeled walker and contact guard assistance. She had issues with knee flexion contractures when she began PT in September, and progressed to her optimal functional level of ankles, knee, and hips upon his discharge from PT on 09/20/16. She was then referred to restorative nursing services for maintenance of the lower extremities and ambulation. Upon inquiry, physical therapist #127 said PT screens this resident quarterly. Her most recent screen occurred on 11/30/16, where she was found at that time to not have a decline in her activities of daily living or functionality, and there were no changes in the contractures. On 12/14/16 at 3:20 p.m., an interview was completed with restorative nurse #38. She said restorative service is doing bilateral lower extremity range of motion and ambulation three (3) to six (6) times per week. She said restorative is not performing any range of motion to the upper body or upper extremities. She reviewed her records, and found no referrals from OT for any restorative services to the upper body or upper extremities. Restorative nurse #38 then spoke with physical therapist #127 by telephone. She relayed to the physical therapist that they only have this resident for ambulation and lower extremities range of motion. A second interview was then conducted with physical therapist #127 on 12/14/16 at 4:00 p.m. She provided a copy of the OT discharge summary dated 02/09/16. The OT discharge summary addressed that the resident refused orthotic devices, but will continue with range of motion of the bilateral hands and will continue with bilateral shoulder flexion program, both through restorative nursing services. The resident at that time was discharged to the long-term care facility with a range of motion program to facilitate the resident maintaining her current level of performance, and to prevent decline. Per the OT discharge summary, development of and instruction in the following restorative nursing program was completed with the interdisciplinary team: Range of motion (active) and range of motion (passive). Upon inquiry, physical therapist #127 spoke her opinion that this resident needs range of motion to her hands and shoulders. She said that somewhere along the way, range of motion restorative services got lost in the shuffle. An interview was conducted with the administrator on 12/14/16 at 4:30 p.m. She acknowledged the concern with the resident having no range of motion services to the upper body and upper extremities since February, (YEAR). On 12/15/16 at 12:30 p.m. an interview was conducted with nursing assistant #53. She said this resident has contractures of both hands, moreso on the left. She added that in the past the facility tried hand splints (orthotics) but the resident did not like them and would not use them. She said restorative nursing services ambulates her in the hall and does range of motion to her joints nearly every day. Upon inquiry, she said that none of the aides do range of motion on this resident, rather, restorative nursing service performs that task.",2020-09-01
1918,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-12-16,332,D,0,1,R3ET11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review the facility failed to ensure a medication error rate of less than 5%. A nurse administered the wrong medication to Resident #150 and #154. Resident #45 received a steroid inhaler without instructions to rinse mouth upon completion. This is true for three (3) of seven (7) residents observed during medication pass resulting in a medication error rate of 7.14%. Resident identifiers's: #150, #154 and #45. Facility census: 90. Findings include: a) Resident #150 During medication pass on 12/14/16 at 8:27 a.m., Resident #150 was given a Senna 8.6 mg/[MEDICATION NAME] 50 mg tablet. Review of the current physician orders [REDACTED]. At 10:15 a.m., licensed nurse #114 agreed the Resident #150 was given Senna 8.6 mg/[MEDICATION NAME] 50 mg when [MEDICATION NAME] 100 mg was prescribed by the physician. b) Resident #145 During observation of medication administration on 12/14/16 at at 8:03 a.m., licensed practical nurse #114 gave two (2) tablets of [MEDICATION NAME] 50 milligrams/Senna 8.6 milligrams to Resident #145. The nurse obtained that medication from a bottle of stock medications kept in the top drawer of the medication cart. Review of physician's orders [REDACTED]. Also, the Medication Administration Record [REDACTED]. This information was relayed to nurse #114 at this time. She said she would obtain a stock bottle of plain [MEDICATION NAME] for the medication cart. On 12/15/16 at 9:00 a.m., the administrator was informed of the medication error rate greater than five (5) per cent, and the details of those errors. c) Resident #45 During observation of medication administration on 12/14/16 at 8:13 a.m., licensed practical nurse #34 administered Symbiocort via a hand-held aerosol to Resident #45. The nurse did not offer the resident a cup of water to rinse his mouth and spit after using this inhaler which contained a steroid. The resident said, when asked specifically, that he sometimes rinses his mouth after using the Symbiocort, but only if the nurse brings him a cup and lets him rinse his mouth and spit at the bedside. He explained that he is unable to get out of bed by himself to go to the sink. Review of the Medication Administration Record [REDACTED]. It contained further directives to rinse the mouth with water after administration and Do not swallow the rinse water. Review of physician's orders [REDACTED]. The physician's orders [REDACTED]. An interview was conducted with the consultant pharmacist on 12/14/16 at 3:00 p.m. She said that nurses are supposed to have the residents rinse their mouths and spit after any inhaled medication with steroids such as Symbiocort. She said that is in the manufacturer's instructions, as failure to do so could result in [MEDICAL CONDITION](yeast, or thrush). Facility consultant #132 was present during this telephone interview. On 12/15/16 at 9:00 a.m., the administrator was informed of the medication error rate greater than five (5) per cent, and the details of those errors.",2020-09-01
1919,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-12-16,371,E,0,1,R3ET11,"Based on observation and staff interview the facility failed to ensure food was served under sanitary conditions. Employees did not practice proper hygienic practices by not keeping their hands away from their hair and face when serving meals. In addition, staff's long hair hung over the residents' food plate while staff set up the residents' meals. This practice has the potential to affect all residents who receive food from the kitchen. Facility census: 90. Findings include: a) During an observation of the noon meal service in the main dining room, on 12/12/16 at 12:00 p.m., Activity helpers #122 and #83 were observed repeatedly touching their face and pushing their hair back while serving meals. In addition three of five employees serving meals in the main dining room had long unrestrained hair hanging over the residents' food while assisting them with meal set up. During an interview immediately after this observation, Employee #122 acknowledged touching her face and hair and agreed staff should sanitize their hands after touching their face and hair. On 12/12/16 at 12:15 p.m., Restorative aide #77 was observed scratching her face, neck and head after sanitizing her hands. She preceded to the drink cart and served Resident #20 without washing and/or sanitizing her hands. Employee #77 acknowledged she had touched her face and hair multiple times because of itching during an interview immediately after this observation. A follow observation of the main dining room on 12/13/16 at noon revealed staff's long hair was pulled backed and contained during meal service. The Infection Control Nurse #75 was interviewed on 12/14/16 at 10:43 a.m. She confirmed staff hair should be pulled back during meal service to prevent it from hanging over the residents' food and staff should wash and/or sanitize their hands after touching their face or hair during tray pass.",2020-09-01
1920,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-12-16,441,D,0,1,R3ET11,"Based on observation and staff interviews, the facility failed to implement practices and processes designed to prevent infection and/or cross-contamination for one (1) of two (2) residents reviewed in Stage two (2) of the Quality Indicator Survey (QIS) for urinary catheter use. The facility failed to adhere to infection control practices while performing catheter care for Resident #149. This failed practice had the potential to affect more than a limited number of residents. Resident identifier: #149. Facility census: 90. Findings include: a) Resident #149 On12/15/16 at 9:07 a.m., the provision of pericare/catheter care for Resident #149, by nurse aide (NA) #104 and NA #56 was observed. Observations revealed NA#104 upon removing a brief from Resident #149 placed the brief, at the foot of the resident's bed directly on the sheet. Further observation revealed Resident #149 accidently placed her left foot inside the brief that was left lying on the bed. Interview with NA#104 and NA#56 after pericare/catheter care was given revealed both NAs agreed they had been trained not to lay a brief that had been removed from the resident on the resident's bed. Both NAs agreed that laying it directly on the sheet without a barrier was a breech in infection control principle and practice. NA#104 agreed other options to prevent the breech in infection control could have been to dispose of the brief in the trash can sitting beside the bed or even asking NA#56's help in disposing of the brief instead of lying it directly on the sheet.",2020-09-01
1921,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-12-16,465,E,0,1,R3ET11,"Based on observation and staff interview the facility failed to ensure a safe, functional sanitary, and comfortable environment for residents. The [NAME] Court shower room floor was uneven with multiple areas of cracked and missing floor tiles. This has the potential to affect all residents that use this shower room. Facility census: 90. Findings include: a) An observation of the shower room on the 100-200 hall ([NAME] Court) on 12/12/16 at 11:20 a.m., found multiple cracked floor tiles in the large shower area. The shower floor was wavy and uneven, floor tiles were missing, and the floor was separated from the wall in the large shower area. The Director of Nursing viewed the [NAME] Court shower room on 12/12/16 at 11:35 a.m., and confirmed the residents on the 100 and 200 hall use the shower room; and the wavy, cracked and missing floor tiles need replaced.",2020-09-01
4994,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2015-09-10,279,D,0,1,4FFS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan based on a resident's current health condition/status that included measurable objectives and timetables to meet a resident's medical, nursing and psychosocial needs. One (1) of five (5) Stage 2 sample residents whose care plans were reviewed. for unnecessary medications. during the Quality Indicator Survey (QIS) was affected. Resident #10's care plan did not address antiplatelet therapy. Resident identifier: #10. Facility census: 86. Findings include: a) Resident #10 On 09/10/15 at 12:15 p.m., a medical record review conducted for Resident #10 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. As a treatment for [REDACTED]. At 1:00 p.m. on 09/10/15, a review of the care plan dated 08/17/15 for Resident #10, revealed an absence of a focus, goal, and interventions related to the resident's antiplatelet therapy. After reviewing the care plan on 09/10/15 at 1:15 p.m., the Minimum Data Set (MDS) Coordinator #18, verified the care plan did not contain information related to Resident #10's antiplatelet therapy. MDS Coordinator #112 entered during the interview with MDS Coordinator #18 and explained that she Normally does Resident #10's MDS and care plan. She commented it was not coded on the MDS, then stated, But I won't say whether it should be on the care plan. After reviewing her medication reference book, she stated, Yes, I guess it should be care planned because of bleeding.",2019-04-01
4995,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2015-09-10,371,F,0,1,4FFS11,"Based on observation and staff interview, the facility failed to ensure food was stored under conditions which prevented foodborne illnesses to the extent possible. Raw meat was stored in a manner that did not prevent potential cross-contamination of other foods in the refrigerator. Perishable food items were not dated to keep track of when to discard them. Expired food items were also present in the walk-in refrigerator. This practice had the potential to effect all residents at the facility. Facility census: 86. Findings include: a) Tour of the kitchen At 10:45 a.m. on 09/08/15, during an observation of the walk-in refrigerator with Dietary Manager (DM) #112, foods were observed stored improperly. A box of uncooked bacon was stored on the rack above a tray containing fourteen (14) Styrofoam containers of pineapple tidbits. DM #112 stated the uncooked bacon should not be stored over the tray of pineapple. He stated, I will throw the pineapple away. At 2:20 p.m. on 09/10/15, a second visit to the kitchen with DM #112, found four (4) small plates containing yellow cake and several bowls of vanilla pudding with a discard date of 09/09/15. Also present in the walk-in refrigerator were plates of cottage cheese with pineapple, and a tray containing several pieces of yellow cake with cool whip. These items were stored with no dates to indicate when the items were prepared and no dates to indicate when to discard the items. .",2019-04-01
4996,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-04-28,164,D,1,0,47EZ11,"> Based on observation and interview, the facility failed to provide visual privacy to one (1) of six (6) residents on the sample. The resident was not provided privacy during an observation of a dressing change and personal care. Resident identifier: #5. Facility census: 94. Findings include: a) Resident #5 During an observation of Resident #5 on 04/27/16 at 10:45 a.m., Licensed Practical Nurse (LPN) #73, completed a dressing change on the resident's right ankle and applied cream to the resident's feet and back. The LPN raised the resident's pants up to her knees as well as the back of her shirt up to her neck. Neither the resident's bedside curtain, nor the door to the room were closed during the care. The resident was in full view of anyone passing in the hallway. In an interview on 04/27/16 at 11:00 a.m., LPN #73 stated she was nervous and forgot to close the door to Resident #5's room. The LPN stated the resident's curtain or door should always be closed when providing care.",2019-04-01
4997,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-04-28,309,E,1,0,47EZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to obtain physician's orders for medications upon admission and/or failed to administer medications as ordered. Multiple medication error reports were completed for (MONTH) and (MONTH) (YEAR), including errors where residents did not receive their medications. This had affected more than a limited number of residents, prior to the facility implementing corrective actions. Resident identifiers: #7, 8, 9, 10, and 11. Facility census: 94. Findings include: a) On 04/27/16 at 10:30 a.m., review of the Medication Error Report sheets for the past three (3) months found there were nine (9) reports where a resident had not received medication. 1. Resident #7 On 02/13/16 this resident was supposed to have her [MEDICATION NAME] 25 milligrams (mg), a pain medication, changed at 10:00 p.m. and it was not done. 2. Resident #8 On 02/19/16 at 6:00 a.m. this resident was supposed to receive [MEDICATION NAME] ([MEDICATION NAME] extended release), a pain medication, 45 mg and it was not given. Two (2) other errors were reported for this resident. On 03/08/16 he was supposed to receive [MEDICATION NAME] mg at 8:00 a.m. and again at 2:00 p.m., and the medication was not given. 3. Resident #9 This resident was ordered to have Vaseline applied to a biopsy area for two (2) weeks after the procedure. It was not until 03/12/16 that it was discovered he had not received the Vaseline treatment for [REDACTED]. 4. Resident #10 -- Upon admission to the facility on [DATE], this resident's discharge summary from a prior facility reported to continue his medications. These medications were not ordered by the facility upon the resident's admission. The date of discovery was 03/26/16. The medication was [MEDICATION NAME] 2.5 mg every day for hypertension (high blood pressure). -- A second medication, [MEDICATION NAME], one (1) gram twice a day (also known as [MEDICATION NAME], an antibiotic) was ordered to be given on 03/22/16 at 8:00 a.m. and was not given. The error was attributed to incomplete printing of the Medication Administration Record [REDACTED]. 5. Resident #11 Three (3) medications were missed for this resident after admission from another facility on 03/25/16: Lubricant eye ointment 0.25 inches both eyes at bedtime, [MEDICATION NAME] HFA one (1) puff orally four times daily, and [MEDICATION NAME]-tazobactam (an antibiotic known as [MEDICATION NAME]) 4.5 grams intravenously every six (6) hours. The time of discovery of these omissions was 7:00 p.m. on 03/26/16. b) During a discussion of these findings with the director of nursing on 04/27/16 at 11:20 a.m., she stated the facility had undergone some staffing changes and there were measures in place to address these medication errors. As a result, the medication errors were no longer occurring. She provided documentation of a nurses' meeting held 04/04/16, with an itinerary regarding medication ordering, discontinuation of medications, and chart checks. It was discussed that although there had been several medication errors in the past three (3) months, there had been no errors since 03/25/16, which was a month prior to this investigation.",2019-04-01
5135,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-03-09,157,D,1,0,K6OL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review, staff interview, confidential interview, and family interview, the facility failed to promptly consult with a resident's physician and notify the resident's legal representative during a significant deterioration in Resident #94's condition overnight. The resident became lethargic and had an elevated temperature. She subsequently had a decreased level of consciousness, full body tremors, and further elevated temperature for which she was sent to the hospital. This was found for one (1) of six (6) residents reviewed. Resident identifier: #94. Facility census: 95. Findings include: a) Resident #95 This [AGE] year-old woman, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Her daughter acted as her decision-maiker as the resident's physician determined the resident lacked the capacity to make informed medical decisions. The review of her record began on 03/02/16 at 11:32 a.m. The record stated as of 12/12/15, she was being treated with an antibiotic for an upper respiratory infection. She was alert and verbal. Pertinent progress notes were found for the afternoon and evening of 12/12/15, and the morning of 12/13/15 as follows (typed as written): -- 12/12/15 (10:46 a.m.) Nurse's Note: Resident is alert and verbal resting in bed at this time. CNA (certified nurse aide) alerted this nurse that resident was not acting like herself. Resident vs (vital signs) take BP (blood pressure) 127/55 p (pulse) 88 Temp (temperature) 100.2 RR (respiratory rate) 32 SP02 (oxygen saturation) 88% on 2L (two liters) of 02 (oxygen). Resident is having jerking involuntary movements. Lung sound diminished in bases and upper crackles noted. Resident states she is not feeling well. MD (doctor) contacted and new orders received for UA (urinalysis) C&S (culture and sensitivity) CBC (complete blood count) and to dc (discontinue) zpack (Zythromax - an antibiotic) and start [MEDICATION NAME] (antibiotic) x (times) 10 days. Residents MPOA (Medical Power of Attorney) (Daughter) contacted and notified of current condition and new orders. Resident denies any pain at this time. -- 12/12/15 (11:07 a.m.) Nurse's Note: Resident straight cathed (catheterized) using sterile tech (technique) to obtain ua/(urinalysis) C&S. Resident tolerated procedure well. Cloudy amber urine with strong odor noted. -- 12/12/15 (2:26 p.m.) Nurse's Note: Residents MPOA and MD notified of recent chest xray results which were negative. UA and labs are still pending. c) The facility's Minimum Data Set (MDS) assessment coordinator, Registered Nurse (RN) #106, covered the first portion of the shift as the evening of 12/12/15 began. Her entries were: -- 12/12/15 (6:30 p.m.) Nurse's Note: Resident weak and had difficulty feeding herself supper. CNA feed her supper to her and she ate a bowl of tomato soup and a grilled cheese sandwich. She denied any pain just stated she felt really weak. Will continue to be observed for any further problems. Spoke with her daughter (name) and notified her of the lab results with CBC and UA. Still waiting on the urine culture. -- 12/12/15 (6:40 p.m.) Nurse's Note: Paged Dr. (name) in regards to lab results of CBC and UA. Awaiting return call. -- 12/12/15 (6:51 p.m.) Nurse's Note: Resident noted with weakness in upper extremities. When trying to hold the phone up to her ear or feed herself her arms would begin jerking and she was unable to hold them up. It appeared that when she tensed her muscles they were too weak to hold up. -- 12/12/15 (7:33 p.m.) Nurse's Note: Dr. (name) returned phone call. Results of UA and CBC given to him. He stated that the [MEDICATION NAME] she is on will cover the possible UTI. She had cloudy urine with protein 30, positive [MEDICATION NAME] and large leudocytes, WBC's > (greater than) 182 and many bacteria. Culture still pending. Order obtained for Chemistry panel Mon. (Monday) 12/14/2015. Daughter (name) notified of results of labs and orders obtained. She also had ask earlier about the calcium being discontinued and Dr. (name) said that because of her [DIAGNOSES REDACTED]. Will continue to observe. d) In an interview on 03/08/16 at 10:42 a.m., RN #106 said when she spoke with the physician and the daughter of Resident #94 at 7:33 p.m., there was understanding of her condition and agreement to continue current treatment and observations. She was relieved by another nurse following that note of 12/12/15 at 7:33 p.m. e) There were only two (2) nurses' notes documented following 7:33 until Resident #94 was apparently sent to the hospital on [DATE] at sometime around 4:30 a.m. (typed as written): -- 12/12/15 (10:07 p.m.) Nurse's Note: Resident cont (continued) to be lethargic, does respond at times to verbal stimuli. Turned and repositioned q (every) 2 hrs (hours) for skin integrity. O2 @2L via n/c in place per order. SPO2 93%. Tylenol 650mg (milligrams) given for elevated temp 100.1 PO (by mouth). Will cont to observe. call bell within reach. -- 02/13/15 (4:48 a.m.) SBAR (Situation Background Assessment Recommendation) Nurse's Note: Elevated temp of 101.0 PO. Increased full body tremors. The resident has orders for the following advance directives: DNR (Do Not Resuscitate). resident had increased temp, decreased L[NAME] (level of consciousness), body tremors noted. The RN on day shift made the next note which showed Resident #94's daughter called the facility to inform them her mother had been admitted to the hospital: -- 12/13/15 (10:50 a.m.) Nurse's Note: Daughter spoke with LPN (Licensed Practical Nurse) on phone and reported that resident was admitted to hospital with IV ABT (intravenous antibiotics)/cath (catheter)-UTI (urinary tract infection) & (and) increased troponin levels. f) Review found an SBAR communication form and an electronic einteract transfer form. The SBAR form documented the elevated temperature, decreased level of consciousness, and body tremors, that the daughter/medical power of attorbey (MPOA) was notified on 12/13/15 at 4:30 a.m., the physician on call for Resident #94's attending physician was called at 4:30 a.m., and the nurse was awaiting a call back. The transfer form documented Resident #94 was sent to a local hospital on [DATE] at 4:30 a.m., the vital signs sent with the resident were documented as taken on 12/12/15 at 11:53 p.m. g) The nurse on duty who authored the notes of 10:07 p.m. and 4:48 a.m. and the SBAR assessment and transfer form, Licensed Practical Nurse (LPN) #122 was interviewed by telephone on 03/08/16 at 12:10 p.m. She said she thought Resident #94 should go to the hospital, but she could not send her without speaking to the physician or the MPOA. h) In an interview on 03/-8/16 at 4:45 p.m., Director of Nursing, RN #17, said the optimal situation for transfer was that a physician's orders [REDACTED]. If that could not be obtained, the Director of Nursing or Nurse on Call should be contacted. If that could not be accomplished, then a nursing judgment should be made and the resident sent out for assessment. i) Resident #94's MPOA, when interviewed on 03/08/16 at 4:20 p.m., said she had received no calls from the facility during the night of 12/12/15 until the early morning of 12/13/15, when she demanded her mother be sent to the hospital. j) There was no evidence of any attempts by the facility to contact the physician, the MPOA, the Director of Nursing, or the nurse on call after 7:33 p.m. on 12/12/15 until 4:30 a.m. on 12/13/15.",2019-03-01
5136,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-03-09,225,D,1,0,K6OL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon resident interview, staff interview and review of records, the facility failed to immediately report Resident #70's allegation of verbal abuse as required. This was found for one (1) random resident. Resident identifier: #70. Facility census: 95. Findings include: a) Resident #70 This [AGE] year-old woman, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. She was determined by a physician to possess the capacity to make informed medical decisions. She is acting as her own responsible party. When greeted during a tour of the facility on 03/08/16 at 10:00 a.m. Resident #70 said she had some concerns she wanted to discuss. She said two (2) nurse aides (NAs) had been really mean to her recently. She said within the past week the NAs had yelled at her and said they were not going to provide care for her, she had to do it herself. She said she considered this verbal abuse and she had reported it to one of the new social workers. In an interview on 03/08/16 at 11:55 a.m. with the two (2) new Social Workers, #38 and #55, when asked if Resident #70 had told them two (2) NAs had been mean to her recently, Social Worker #38 said she had spoken with her yesterday about her roommate and she had told her two NAs had been mean. She said the resident had given her their names. Review of the resident's record found a social services note that stated (typed as written): -- 03/07/16 at 3:57 p.m. Social Service Note: This SW spoke with (Resident #70) regarding a room change, she states her roommate keeps their room too hot and she can't stand it, especially with summer coming and the temperature outside will be warm too, and her room mate still keeps it hot in the room. SW asked if she was willing to move to (name of wing) side and she stated no. I explained that it has been looked at but anyone who does not have a room mate keeps their room hot also. Assured (resident #70) that it will continue to be looked into and not forgotten. There was no mention of the resident's allegation about the NAs. Review of facility's complaint files and abuse/neglect reporting records on 03/09/16 at 11:00 a.m., found no complaints had been documented from Resident #70 and no immediate report of an allegation of abuse/neglect had been submitted to the required State agencies within twenty-four (24) hours after it was received. In an interview with Social Worker #38 on 03/09/16 at 2:20 p.m., she said she had completed a report of the allegation today and the investigation was underway. She expressed understanding the allegation should have been reported within twenty-four (24) hours.",2019-03-01
5137,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-03-09,309,E,1,0,K6OL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review, review of facility incident reports and assessments, and review of HCPro's Long-Term Care Nursing Library, (MONTH) 8, 2013 related to neurological checks in long term care facilities, the facility's policy and procedure for neurological checks following unwitnessed falls and falls with head injury, and staff interview, the facility failed to ensure neurological assessments were completed consistently and accurately based upon common standards of practice and facility policy. This was found for six (6) of six (6) residents whose records were reviewed, and had the potential to affect more than an isolated number of residents with falls. Resident identifiers: #94, #91, #90, #6, #38, and #83. Facility census: 95. Findings include: a) A complaint under investigation included an allegation that residents were not medically assessed appropriately following falls. Based upon review of the facility's incident reports for the previous three (3) months, a sample was chosen to include six (6) residents who had falls with head injury and/or had unwitnessed falls. 1. Resident #6 This [AGE] year-old man, admitted to the facility on [DATE] had [DIAGNOSES REDACTED]. Beginning on [DATE] at 12:15 p.m., review of his medical record for post fall interventions and documentation of neurochecks found on [DATE] at 3:57 a.m., the resident experienced a fall. The incident report, requested from Administrator #41 on [DATE] at 9:35 a.m., identified the resident was found on the floor with a laceration above the left eye which was bleeding. The medical record stated neuro checks were initiated. 2. Resident #38 This [AGE] year-old woman, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Review of her medical record, beginning on [DATE] at 2:13 p.m., found she experienced falls on: -- [DATE] at 4:00 a.m., -- [DATE] at 7:47 p.m., and -- [DATE] at 2:45 a.m. Review of the incident reports, requested from Administrator #41 on [DATE] at 9:35 a.m., found: -- The report for [DATE] documented an unwitnessed fall at 4:00 a.m. The record stated neuro checks were initiated. -- The report for [DATE] documented an unwitnessed fall at 7:47 p.m. The record stated neuro checks were initiated. -- The report for [DATE] documented an incident when the resident was found on her bedroom floor. She had a knot on the left side of her forehead. The record stated neuro checks were initiated. 3. Resident #83 This [AGE] year-old man, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Review of his medical records for post fall interventions and documentation of neurochecks, beginning on [DATE] at 2:35 p.m., found he experienced a fall on [DATE] at 9:50 a.m. The incident report, requested from Administrator #41 on [DATE] at 9:35 a.m., found the report documented the resident was found on the floor on his buttocks with his legs straight. He was leaning to the left on his left arm. There was a puddle of blood on the floor and he had a laceration above his left eye. He was sent to the emergency room for evaluation. The record stated neuro checks were initiated upon his return from the hospital. 4. Resident #95 This [AGE] year-old woman, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Her daughter acted as her decision maker. The review of her record began on [DATE] at 11:32 a.m. Review of incident/accident logs found she experienced a fall on [DATE]. There were also incidents related to bruising logged for [DATE] and [DATE]. The incident reports, requested from Administrator #41 on [DATE] at 9:35 a.m., found the report for [DATE] documented she had a controlled fall during ambulation to the bathroom. She was using a walker and being assisted by a nurse aide. Her legs gave out and she sat on the floor. As she went down her head went sideways and she hit her head on the door facing. She had bruising to her face and the top of her scalp. The record stated neuro checks were initiated. 5. Resident #91 This [AGE] year-old man had [DIAGNOSES REDACTED]. She had been determined by a physician to possess the capacity to make informed medical decisions. The review of her record began on [DATE] at 3:58 p.m. Review of incident/accident logs found she experienced falls on [DATE] at 5:42 p.m., [DATE] at 8:00 a.m., [DATE] at 3:15 p.m., and [DATE] at 4:20 p.m. There were also incidents logged for bruises on [DATE] at 3:12 p.m. and 3:34 p.m. The incident reports, requested from Administrator #41 on [DATE] at 9:35 a.m., included a report for [DATE]. The report noted she was found on the floor in front of her recliner and she complained of pain to her right knee and ankle. The record did not state whether neuro checks were initiated. The falls of [DATE], and [DATE] were witnessed with no head injury. The report of her fall on [DATE] at 4:20 p.m., noted she complained of pain between her shoulders and possible hip pain. She was taken to the hospital. The record stated neuro checks would be initiated upon her return. 6. Resident #90 This [AGE] year-old man, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. The review of his record began on [DATE] at 4:45 p.m. Review of incident /accident reporting logs found he experienced falls on [DATE] at 5:15 p.m. and [DATE] at 11:13 a.m. The incident reports, requested from Administrator #41 on [DATE] at 9:35 a.m., identified on [DATE], he was found on the floor in his room on his left side. There was a one (1) inch laceration to the middle of his forehead. The record stated neuro checks were initiated. The report for [DATE] stated his roommate told the nurse he was on the floor. No injuries were noted. The record stated neuro checks were initiated for this unwitnessed injury. b) There is a standard of practice for the initiation of Neurological checks following a fall with head injury or an unwitnessed fall. An example of this was reviewed on the Internet site of HCPro's Long term Care Nursing Library dated [DATE]. In summary, the article stated (typed as written): 1. Assess the resident for changes in level of consciousness, which is a cardinal sign of untoward pathology. Assess the resident immediately after the fall, then frequently throughout the shift. Assessment should continue for a minimum of 72 hours. 2. Observe the resident for obvious injuries to the scalp, including lacerations, bruises, or contusions; confusion; memory loss; difficulty speaking; gait or balance problems; pupils of unequal size or reactions; headache; vomiting; visual disturbances; or periods of coherence alternating with periods of confusion or lethargy. Monitoring must continue for a minimum of 72 hours (or until the resident is asymptomatic for a specified period of time). 3. Perform frequent neurologic assessments every: 15 minutes for two hours 30 minutes for two hours 60 minutes for four hours Eight hours for 16 hours Eight hours until at least 72 hours have elapsed and resident is stable 4. Neurological assessments include (at a minimum) pulse, respiration, and blood pressure measurements; assessment of pupil size and reactivity; and equality of hand grip strength. Completing the Glasgow Coma Scale immediately, then once each shift following a head injury, helps keep findings objective. c) On [DATE] at 10:00 a.m., review of the facility's corporate policy and procedure entitled Neurological Assessment, dated [DATE], found the purpose of the policy was to provide guidelines for a Neurological assessment: 1) upon a physician's orders [REDACTED]. The procedure stated the neurological assessment should be completed within the Electronic Health Record (EHC). Initiate neurological assessment and complete ongoing assessments for a minimum of 72 hours. The frequency of the neurological assessment was specified as follows: 1. Every 15 minutes x 42. Every 30 minutes x 63. Every hour x 44. Every four hours x 55. Every 8 hours x 6 d) In an interview on [DATE] at 11:10 a.m., Director of Nursing (DON) #17 was asked for documentation of the neuro checks completed for the six (6) sampled residents' falls with suspected head injury or unwitnessed falls in which the documentation stated neuro checks were initiated. When the documentation was provided, there were some apparent concerns. In some cases, the neuro checks were documented to have been initiated before the actual fall was stated to have happened - in some cases hours before the incident report said the fall occurred. There were gaps in some of the documentation, and some of the entries used widely differing times of up to two (2) hours different within the same documented check. The DON #17 was asked to assist with the process of trying to ascribe an agreed upon timeline to the documentation. The result was discussed on the afternoon of [DATE]. The Director of Nursing said she felt some of the nurses were not properly trained in the completion of the electronic health record for incident reporting and neurological assessments. She acknowledged there were problems in at least some portions of all the sampled records. She said she felt the nurses may have been reluctant to change times and dates within fields already populated. Some of the times for falls on the incident reports were in error by as much as nearly four (4) hours such as the [DATE] fall of Resident #94. The incident report documented the fall occurred at 3:12 p.m., but the DON believed the fall actually occurred around 11:45 a.m. She could not explain why some of the documentation for the same neuro check would contain different times for different measures, such as: -- the neuro check for Resident #6's fall of [DATE] at 3:57 a.m., in which there is a documented check on [DATE] at 5:45 a.m. of blood pressure, temperature, pulse, and respiration followed by a check at apparently at 6:00 a.m. which included a pulse taken at 7:58 a.m., and a check at 6:15 a.m. which included a temperature taken at 8:03 a.m. These were all apparently 15 minute checks although the incident report documented the fall happened at 3:57 a.m. The Director of Nursing acknowledged there were lapses in the scheduled checks in some of the records. She said she was already in the process of scheduling mandatory training in the importance of accurate completion of documentation of incidents and neurological assessments in the electronic record. She said she had been using some of the erroneous times in her tracking and trending of the times for falls for Quality Assurance purposes and would have to go back and revisit those studies. k) The investigation found the facility's documentation failed to support neurological assessments were being completed accurately and consistently according to recognized standards of practice and facility policy. Additionally, as the Director of Nursing noted, the inaccurate times could impact the tracking and trending of falls. Accurate information had the potential to affect the determination of whether the fall had resulted in fall related problems for the individual resident, and to impact how to plan individualized care to prevent additional falls.",2019-03-01
6078,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,154,E,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to fully inform residents who had been determined to possess the capacity to act as their own decision-maker, in a language that he or she could understand, of identified concerns regarding his or her total health status, including their cognitive status and psychosocial status as initiated in their individualized care plans. Residents were not informed of care plans established for behaviors. This was found for four (4) of four (4) residents who had voiced multiple documented complaints during 2013. Resident identifiers: #19, #62, #25, and #57. Facility census: 100. Findings include: a) Review of complaints, concerns, and abuse/neglect reporting began on 01/08/13 at 9:00 a.m. This review was continued and expanded on 01/20/14 as part of the extended survey protocol. 1) Resident #19 Review of the complaint/concern files identified this resident had thirty (30) documented concerns in 2013 to date. According to the documentation regarding these issues, the facility had attempted to resolve all of the resident's issues. The facility had not dismissed any of the resident ' s concerns as being unfounded or untrue. The high number of concerns filed by this resident prompted review of her medical record. This review the resident's physician had determined she possessed the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score, as assessed on 12/17/13, was 15, indicating she was cognitively intact. She was acting as her own decision-maker. Review of her care plan, on 01/16/13 at 1:00 p.m., found she had a focus item for being at risk for changes in behavior problems related to making false accusations towards staff. The goal for this problem was (typed as written), Will remain free of behavioral disturbances daily thru next review. Interventions implemented toward meeting this goal were (typed as written): 1. Anticipate needs and provide care as able. 2. Provide emotional support as needed. Further review of the resident's medical record found there were no behaviors identified on the resident's minimum data set assessments. There was no evidence of any targeted behaviors being quantitatively monitored. There was no evidence of any behaviors, other than the frequency of her complaints. The record review found no basis for establishing the goal of (typed as written), Will remain free of behavioral disturbances daily thru next review. b) Following the review of Resident #19's medical record, patient liaison, Employee #176, was asked on 01/20/14 at 11:48 a.m., to provide a listing of residents who had voiced the most complaints and concerns in 2013. She provided the requested information a short time later, which indicated the following: 1) Resident #62 This resident had eleven (11) complaints/concerns/grievances documented. Resident #62 had been determined by a physician to possess the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score as assessed on 01/09/14 was 15, indicating she was cognitively intact. She was acting as her own decision-maker. She was currently president of the resident council. Review of her care plan, on 01/16/13 at 1:10 p.m., found she had a focus item for being at risk for behavior symptoms related to fabrications of staff refusing care/frequently making accusations toward staff and other residents. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer medications per physician order. 2. Observe for mental status/behavior changes when new medication started or with changes in dosage. 3. Resident refuses psychiatric evaluation. 4. Use consistent approaches when giving care. 2) Resident #25 A review of the closed medical record for Resident #25 revealed she had been determined by a physician to possess the capacity to make informed medical decisions. This was verified in each of her care plan meeting minutes 07/24/13,08/08/13, and 10/16/13). She had scored 15/15 on the BIMS (Brief Interview for Mental Status) on 10/18/13. She was her own decision-maker during her stay at the facility. A review of the Concern Report files revealed Resident #25 had nine (9) grievances documented during her admission at the facility from 07/23/13 to 11/08/13. Review of the complaints and concerns found that the facility had attempted to resolve all of the issues. None had been dismissed as being unfounded or untrue. A review of her care plan, at 1:37 p.m. on 01/16/13, found she had a focus item for being noted to make false accusations towards staff related to [MEDICAL CONDITIONS]. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer medications per physician order. 2. Observe for mental status/behavior changes when new medication started or with changes in dosage. 3. Use consistent approaches when giving care. Medical record review found that although she had a care plan focus item related to being at risk for behaviors due to making false allegations or fabrications, there was no evidence of behaviors documented on the resident ' s comprehensive assessments (MDS) or any other systematic behavior monitoring that caused these focus items to be triggered for inclusion in their care plans. The only progress note in the entire record alluding to behaviors was the following on 10/18/13, which was the initiation date of the care plan for this focus, (typed as written) Nurse was standing outside of room passing medications when resident call light came on. Nurse finished passing pills that were already started. Nurse answered call light. Resident states, ' Its about time my call light has been on for an hour. ' Nurse explained to resident that she was standing outside of the room when the call light came on but I would be glad to assist her in repositioning. Resident states, ' You are just like everyone else, liars. ' Will continue to monitor. There was no entry in any of the physician's progress notes suggesting the presence of any behaviors. An interview was conducted with acting social services director, contracted Employee #44 on 1/21/14 at 11:50 a.m. She was identified by the Administrator, Employee #120 as the person responsible for facilitating resident care plan meetings. She was asked about general procedures during care plan conferences when a resident acting as their own decision-maker was in attendance, specifically if each focus item would be discussed with the resident. She said each department would in turn bring up all the items on their section of the care plan for discussion, and confirmed that, if an issue was significant enough to be initiated as a focus area on the care plan, it would be discussed during the conference with the responsible party. There was no evidence of behaviors being discussed in any of her care plan meeting minutes (07/24/13, 08/08/13, and 10/16/13) and her daughter had been in attendance at two (2) of the meetings. 3) Resident #57 This resident had eight (8) complaints/concerns/grievances documented. Resident #57 had experienced a recent significant change of condition and was determined by her physician to lack the capacity to make informed medical decisions on 12/27/13 due to illness/early dementia. Prior to that determination, she had acted as her own responsible party throughout her residency in 2013. Her Brief Interview for Mental Status (BIMS) score, as assessed on 11/27/13 was 15, indicating she was cognitively intact. Review of her care plan on 01/16/13 at 1:42 p.m. found she had a focus item for being at risk for behavior symptoms such as making false accusations towards staff and family related to mental illness and [MEDICAL CONDITION]. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer meds per physician orders, observe for effectiveness and side effects such as but not limited to dizziness, drowsiness, and falls. 2. If resident exhibits inappropriate behaviors, speak in a soft, calm tone, attempt to redirect, and encourage resident to express herself in a more appropriate manner. 3. Observe for mental status/behavior changes when new medication started or with changes in dosage. 4. Use consistent approaches when giving care. c) Review found each of these residents had care plan focus items related to being at risk for behaviors due to making false allegations or fabrications, although none of them had evidence of behaviors documented on their comprehensive assessments (MDS) or any other systematic behavior monitoring that caused these focus items to be triggered for inclusion in their care plans. d) In an interview with the acting social services director, contracted Employee #44, on 01/21/14 at 11:50 a.m. (she was identified by administrator, Employee #120, as the person responsible for facilitating resident care plan meetings), she was asked about general procedures during care plan conferences when a resident acting as their own decision-maker was in attendance, specifically if each focus item would be discussed with the resident. She said each department would in turn bring up all the items on their section of the care plan for discussion, and confirmed that, if an issue was significant enough to be initiated as a focus area on the care plan, it would be discussed during the conference with the responsible party. It was then discussed that review had found those residents having the most complaints all had care plan focus items bringing their credibility into question. She was asked if the focus item related to making false allegations or fabrications had been discussed with these residents. She said they had not.",2018-05-01
6079,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,155,E,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure four (4) of thirty-four (34) sample residents were afforded the right to formulate an advance directive. The facility failed to clarify and periodically review existing advance directives. Advance directives were not accurately documented to effectively communicate the resident's choices to the direct care staff should the need to implement, or not implement, cardiopulmonary resuscitation (CPR) arise. Resident identifiers: #114, #130, #99, and #5. Facility census: 100. Findings include: a) Resident #114 A medical record review was conducted on [DATE]. Resident #114 had a FULL CODE sticker on his condition alert tab in the chart. A green page in the chart stated Full Code. The monthly physician's orders [REDACTED]. (A full code would mean the facility would attempt to resuscitate the resident.) The resident's West Virginia Physician order [REDACTED]. The POST form was signed by the medical power of attorney on [DATE], and was signed by the physician on [DATE]. The information on the POST form was not transferred to the remainder of the medical record. b) Resident #130 Resident #130 was admitted to Hospice services on [DATE]. A copy of a physician's prescription on the medical record stated Please make patient DNR (do not resuscitate) dated [DATE]. This information was not updated in the medical record. His condition alert tab stated FULL CODE. A green page in the medical record stated Full Code. A sticker was placed on this page stating, Do Not Thin From Chart. A physician's orders [REDACTED]. No POST form was in the medical record. c) Resident #99 The condition alert tab in the medically record of Resident #99 did not address the code status of Resident #99. A Medical Power of Attorney, notarized [DATE], stated Do Not Resuscitate. The physician's orders [REDACTED]. No POST form was present. This medical record provided conflicting information in regards to the resident's choice of code status. d) Resident #5 A POST form, signed by the physician on [DATE], was marked Do Not Resuscitate. The physician's orders [REDACTED]. The condition alert tab, which was intended as a reference for staff, had a sticker stating FULL CODE. e) Staff interviews were held on [DATE] at 12:00 p.m. with the licensed nurses on duty. Employee #151, an agency Licensed Practical Nurse (LPN), stated she relied on the sticker on the Condition Alert tab as a reference in an emergent situation regarding the resident's condition Employee #69, LPN, stated she also referred to the sticker on the Condition Alert tab. Another LPN, Employee #110, stated she looked for a red or green paper in the chart to let her know the code status of a resident and compared it to the POST form. Employee #52, LPN, stated she looked on the Condition Alert tab and compared it to the POST form. The conflicting information found in the medical record and among staff members in regards to code status was discussed with the Administrator, Employee #120, and the Director of Care Delivery, Employee #124, Registered Nurse (RN) on [DATE] at 1:00 p.m. They acknowledged there was conflicting information in the residents' medical records. A policy, revised ,[DATE], was provided titled, Emergency Management code status identification. This policy stated, Review and documentation of new physician orders [REDACTED]. Employee #120 stated a new process was going to be put into place effective immediately due to the breakdown of the current system.",2018-05-01
6080,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,166,E,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, review of snack-related forms provided by the dietitian, review of resident council minutes, resident interviews, and staff interviews, the facility failed to actively seek a resolution to grievances and/or to keep the resident informed of the progress being made. Residents had voiced reoccurring concerns regarding the availability and/or the variety of snacks available when the kitchen was closed; and/or the extended length of time required for care needs to be met for fifteen (15) of thirty (30) residents interviewed. Resident identifiers: #62, #64, #7, #70, #15, #133, #115, #84, #88, #58, #19, #65, #141, #210 and #78. Facility census: 100. Findings include: a) Grievance: Snacks are not available and/or there was no variety of snacks when the kitchen was closed: 1) Resident #62 During an interview with Resident #62 at 3:30 p.m. on 01/07/14, during Stage 1 of the survey, she said there were few or no snacks kept on the care unit and if you requested something when the kitchen was not open you could not get it. She stated this was true for both food and/or drinks. The resident said she had stated this concern during resident council meetings, to the dietitian, at food club meetings, and to the nursing care staff, but nothing had been done. The only answer she received was from a nursing assistant, who said the kitchen would not stock snacks on the unit. 2) Resident #78 An interview with Resident #78 at 2:00 p.m. on 01/08/14, revealed she agreed there were few, if any, snacks available. She stated, If you want a snack they have to go to the kitchen to get it and you can't get anything when the kitchen is closed in the evening. She added, If you wanted something you should have the physician order [REDACTED]. According to the resident, there was usually juice or tea and crackers kept on the unit, but nothing more. She added that this had been brought up at resident council and she had voiced it to nursing staff and the kitchen staff, but she was told there was nothing they could do. 3) As a result of these interviews, the following observations were made during the survey: Observations of the nourishment kitchen serving the 300/400 halls were made at 8:30 a.m. on 01/08/14; 9:30 a.m. on 01/09/14; 3:00 p.m. on 01/13/14; and 8:15 a.m. on 01/14/14 (on 01/14/14 Employee #87 (Maintenance Director) was present). On each of these observations, there were only graham crackers, soda crackers, and individual containers of peanut butter and jelly found. The refrigerator contained orange juice and a large container of tea. There were never more than four (4) individual containers of milk. There was ice cream in the freezer, but no fruit, puddings, cookies, or bread. 4) Observations of the nourishment kitchen serving the 100/200 halls were made at 8:45 a.m. on 1/08/14; 2:00 p.m. on 01/09/14; and 8:15 a.m. on 01/14/14. The only snack items available were graham crackers, soda crackers, and individual containers of jelly and peanut butter. On 01/14/14, there was a partial loaf of bread. The refrigerator contained large containers of sweetened iced tea and orange juice and ice cream. There were no puddings, cookies, or fruits. There was no milk on 01/08/14 or 01/09/14 and only four (4) individual containers of milk on 01/14/14. 5) All observations revealed multiple individual containers of ordered supplements labeled for certain residents. There were also cans of soda, provided by purchasing. 6) At 9:30 a.m. on 01/14/14, following the earlier observation at 8:15 a.m., both nourishment kitchens were stocked with at least a dozen individual containers of milk, 3 cans of soup, bread, 4 puddings, and a 2 covered bowls of canned fruit. Employee #18 (Aide), who was present, stated this was . a lot more than we usually have. They continued to be stocked throughout the remainder of the survey. 7) An additional six (6) resident interviews were completed during Stage 2 of the survey at 8:30 a.m. on 01/16/14. The residents were asked, Can you get a snack in the evening? and What would you like to get?. The responses were: 1) Resident #64: . no snacks unless the kitchen sends them. When asked what she would like to have she said Maybe a sandwich or toast. 2) Resident #15: You get drinks for snacks if you ask for one. He said he would like food. 3) Resident #133: No snacks. The resident said he would like A sandwich. 4) Resident #115: They don't bring snacks. They tell you, 'no extra.' She said she prefers fruit or cookies and milk. 5) Resident #58: They don't keep anything but crackers. She said she would like anything but crackers. 6) Resident #210: You only get a snack if you're a diabetic. The resident said cookies would be nice. All of these residents stated they had questioned the staff about snacks, but it had not resulted in them being provided. Some said they just get their family to bring things in. None of the residents had been told why their requests had not been met. 8) During an interview with Employee #109 (Activity Director), at 10:30 a.m. on 01/08/14, she was asked to explain some of the items on the Resident Council Minutes form as she attended the meetings. One of the items listed under, Compliments, comments, on 08/15/13, was Snack machine items - Would like switched but they state they cannot change them. She explained that the residents used the snack machine a lot and when asked, added that the residents say there are not a lot of snacks on the floor in the evening. She stated she had forwarded these complaints to the dietary supervisor and administration. She was not aware of any action taken. In an interview with the Registered Dietitians, at 11:35 a.m. on 01/08/14, they acknowledged awareness of the lack of snacks stocked in the nourishment kitchens and stated they had no control over this as the food supplies were provided by contract with a contracted company. The dietitian who did the assessments said, when interviewing residents, she asked them if they wanted a snack and what their preferences were. She then added it to their food order and had the kitchen send them out, but she stated she only did this for the residents who wanted a snack on a daily basis. The Senior Dietitian stated the nourishment kitchens were stocked daily in the afternoon by the kitchen from a written request from the unit nurse and signed for by a nurse when received. She also stated the aides sign out snacks when they are taken from the room and provided a copy of the Nourishment Room Snack Sign Out Log for January 2013. 9) During an observation of the nourishment kitchens at 1:00 p.m. on 01/08/14, the sign out logs were absent. Employees #98, #7, and #142 (aides) stated they were not required to sign out items from the nourishment kitchen. Employees #116 and #106 (Nurses) verified there was no sign out form in use. Employee #116 stated there had been such a form but the practice had only been in effect for about a month and was dropped. 10) The Senior Dietitian provided an order for [REDACTED]. Of the four (4) types of milk, only a few containers of 2% milk were observed. 11) During an interview with Employee #15 (Food Service Supervisor), at 9:00 a.m. on 01/09/14, she acknowledged the use of the sign-out form for snacks but agreed it had not been used. for a long time. She stated the kitchen did not provide soft drinks, except for ginger ale for therapeutic use. She admitted awareness of complaints from time to time from the residents about snacks, but stated there was nothing she could do about it and did not explain. She provided a copy of the HCR ManorCare HS Snack Rotation schedule which listed puddings, cookies, ice cream, peanut butter crackers, pretzels,cheese its, and graham crackers. 12) An evening visit at 11:30 p.m. on 01/14/14, revealed the same snack items (and same amount) present in the nourishment kitchens as on the earlier visit on the same day (9:30 a.m.). Interviews with Employees #28, #37, #164, #32, and #20 (aides) revealed they had delivered the labeled HS (bedtime) snacks, but had not offered any additional snacks and none had been requested by residents. They expressed surprise at the amount of snacks available and stated that there was usually only Jugs of tea and a juice, and crackers. Employees #32 and #20 stated Resident #29, who was yelling out at that time, could be calmed at times by getting her up and giving her a sandwich, but there was never anything to fix a sandwich with. All of them agreed with this and all agreed a sandwich or toast was the most requested snack. The aides reviewed the HS (hour of sleep) Snack list and said it appeared accurate, but all stated, except for graham crackers and ice cream, none of these items were stocked in the nourishment kitchens. 13) During an interview with the Senior Consultant Dietitian and Employee #15 (Food Service Supervisor) at 12:50 p.m. on 01/14/14, Employee #15 was asked if she had met with the residents to listen to their concerns/requests regarding snacks. She stated a Food Committee met periodically to discuss issues with the food and she attended these meetings, but she had no authority to promise them snacks. She stated she had forwarded the residents' requests to Administration in the past. 14) In an interview with the Administrator, at 8:30 a.m. on 1/24/14, she acknowledged that she was aware of the residents' concerns about the poor amounts and/or variety of snacks available on the units. She could not show any evidence they had discussed or attempted to alleviate the concerns; or had informed the residents of any plans to do so. b) Grievance: The length of time required before the residents' personal needs are met is too long. Twelve (12) of the twenty-seven (27) residents in the Stage 1 sample, who were deemed interviewable by the facility, stated the caregivers were slow to answer their lights and/or to provide assistance promptly. 1) Resident #115 This resident stated the aide would respond to the light, but say, Wait a minute. and not return for a long time. 2) Residents #62 #133, #19, and #141 These residents were re-interviewed in Stage 2 of the survey. They were asked if they had ever complained about the slow provision of care, and what the results of the complaints were. Each of the residents stated they attended Resident Council. they said the slow answering of lights was frequently expressed during the meetings. A review of the minutes from the previous six (6) months revealed concerns addressed about slow response to needs in five (5) of the six (6) months. The September 2013 and October 2013 minutes indicated the call light problem was . a little bit better, but in November 2013, there were again complaints registered. None of the residents interviewed could state what the facility had done to try to solve this problem. 3) Resident #62 This resident was the resident council president. During an interview at 3:30 p.m. on 01/07/14, she stated she depended on the Regional Ombudsman to tell her what was being done about the concerns made by the residents. She added she did not feel the facility was understaffed. The resident said from her room, which was adjacent to the nurses' station, she could hear the aides talking. She said she heard them say such things as, . not me this time and I'm not going in there again. 4) Residents #64, #7, #70, #15, #115, #84, #88, #58, and #65 These residents were interviewed at 10:00 a.m. on 01/16/14. All had complaints about slow response to care needs and all stated they had reported these complaints to staff. None of them could offer any action taken by the facility to resolve this concern, nor had any of them been offered an explanation of what was being done. 5) During an interview with Employee #109 (Activities Director), at 10:30 a.m. on 01/08/14, she acknowledged she attended all resident council meetings and verified there were usually complaints from the residents about staff being slow to respond to lights. She said these concerns were always relayed to administration via the social worker or director of nurses. She admitted that she did not remember anyone coming to resident council to discuss the concern with them. She was not aware of what action may have been done. 6) Employee #122, a social worker, was interviewed at 2:00 p.m. on 01/13/14. She admitted she was aware of the residents' complaints that their lights were slow in being answered. She was not sure what action was planned or if the concern was taken to Quality Assurance Committee. 7) During an interview with the Administrator, a social worker (Employee #175) and the Director of Nursing, and the survey team, at 11:20 a.m. on 01/15/14, they acknowledged awareness of complaints related to the slow answering of lights, but stated action was taken whenever a complaint was made. The minutes of the council meetings were reviewed. The Administrator confirmed there was very little evidence which described what follow-up was done following a complaint. The Administrator assured the group that staffing was adequate. This was verified during the survey. No additional information to validate any response presented to residents individually or to the resident council was provided prior to exit of the facility.",2018-05-01
6081,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,225,F,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of complaint files, review of incident reports, review of personnel files, and staff interview, the facility failed to ensure all allegations of mistreatment, neglect, injury of unknown origin, or abuse were reported immediately to the appropriate State agencies in accordance with this regulation and with Code of State Rules, Title 64 Series 13 - Nursing Home Licensure Rule for West Virginia. The facility also failed have evidence all allegations were thoroughly investigated. This was found for seven (7) of forty-three (43) documented grievances/concerns reviewed. Additionally, the facility had not ensured it did not employee individuals who had been found guilty of abuse, neglect, or mistreatment of [REDACTED]. Thirteen (13) of twenty (20) personal files reviewed did not have this information. These issues had the potential to affect all residents. Employee identifiers: #49, #15, #122, #119, #177, #178, #179, #180, #181, #182, #183, #184, and #187. Resident identifiers: #50, #148, #111, #47, #27, #71, and #25. Facility census: 100. Findings include: a) Resident #50 A review of a Concern Form revealed the son of Resident #50 made the following allegations during the course of a care plan meeting attended by both the resident and his son on 01/09/14: 1. Resident #50's trash can and/or phone were frequently not within the reach of the resident. 2. The resident was receiving poor nail care. 3. Resident #50 stated he gets poor response time to his call light. A written report was completed for each of these allegations on 01/09/14. The concerns were assigned to Employee #116 (RN and Director of Care Delivery) on 01/10/14, to be resolved by 01/15/14. Notices were distributed to All nursing staff in service on 01/10/14, instructing corrective action to be taken regarding the allegations and the following Resolution of Concern was written on the forms and signed by Nurse #116 - At this time, resident et (and) family are satisfied (sign for 'with') actions taken by facility to correct these concerns. Will cont. (continue) ongoing communication (sign for 'with') resident et family to ensure concerns are resolved. There was no evidence the allegations of neglect were reported to the appropriate State agencies as required, nor was there evidence the allegations were thoroughly investigated. b) Resident #148 Review of a facility Concern Form revealed Resident #148 had voiced a complaint to Employee #80 (Occupational Therapist) at 6:30 a.m. on 12/20/13, when she entered his room. His TED (antiembolitic) hose were on at that time. The resident told the therapist they had been left on for two (2) days and nights, when they were supposed to be taken off at night. He also stated he had asked someone to take them off and they said they would, but did not. An incident report was also filed and the resident's physician was informed. The form was signed by Employee #77 (Director of Nursing), but no one was assigned to take action on this concern. There was a partially completed State Report attached to the Concern form, but there was no evidence the resident's allegation of neglect was either reported to the appropriate State agencies, or that any type of investigation had been made. There was no indication the facility staff had notified the resident of any action taken to ensure this did not reoccur. c) Resident #111 A concern form, reviewed, at 10:00 a.m. on 01/14/14, included Resident (#111) found in bed (sign for 'with') wet sheet, dried brown urine circled on sheets. Resident's hair even saturated (sign for 'with') urine. Resident was cold, wet and shivering. The date on the form was 12/20/13 at 8:30 a.m., but it did not state who found the resident in that condition. A nurse (no longer at the facility) was assigned the concern for resolution on 12/21/13. There was no other indication of her involvement. A nurse, Employee #124, completed an incident report on 12/20/13, which noted the family was notified. Employee #77 (Director of Nursing) documented Interviewed LN & CNAS (licensed nurse and certified nursing assistants) caring for resident during shift prior to reported concern. Care provided prior to end of shift and Investigation completed. Care determined to be provided. The completion date on the form was 12/22/13. There was no attached evidence of an investigation. There was no evidence this occurrence was recognized as an allegation of neglect and reported to the appropriate State agencies. When questioned about the incident, at 11:15 a.m. on 01/14/14, Employee #77 confirmed there was no additional information filed, although she did say she talked to the nurse who was working at the time of the incident. d) Resident #47 Review of the facility Concern forms, at 10:00 a.m. on 01/14/14, found a concern form for this resident noted, Resident voiced that she has not been receiving CPM (continuous passive motion) machine (ordered therapy). The resident reported this to Employee #79 (Occupational Therapist) on 12/22/13, who filed the concern form. This allegation of neglect was not reported to the appropriate State agencies and a thorough investigation was not completed. Employee #116 (nurse) was assigned to take action on the concern. The record indicated his determination that the therapy had not been completed on 12/19/14, and Employee #88 (LPN) had confirmed this in a signed statement. Employee #116 indicated he had discovered four (4) missed treatments between 12/19/13 and 12/22/13 and stated in the report that the resident had confirmed the missed treatments. There were no other interviews or information collected. The resolution was education for the staff nurse identified for the single omission on 12/19/14. During an interview with Employee #116 at 1:00 p.m. on 01/14/14, he stated it was given to him as a concern only and he assumed the decision about reporting had already been made. e) Resident #27 Review of the facility Concern forms, at 10:00 a.m. on 01/14/14, revealed a concern reported to Employee #88 (LPN Supervisor) on 12/23/13, by Resident #27. Resident #27 stated Employee #49 (nurse aide) had not gotten her out of bed until late, had left sheets on her bed that were wet with urine, and had not set up her lunch tray. She did not want care from that aide again. The facility did not recognize this as allegations of neglect and did not report the allegations to the appropriate State agencies. The investigation contained only a follow-up interview with Resident #27 and interviews with three (3) other residents. One (Resident #141) had the same complaint about the same aide. f) Resident #71 Review of the facility Concern forms at 10:00 a.m. on 01/14/14, revealed staff reported a skin tear to the right knee and a large bruise on the left lower back of Resident #71 when he was bathed at 12:30 p.m. on 12/03/13. The resident denied any falls and staff documented, Unsure as to exact cause. The facility did not report this bruise of unknown origin to the appropriate State agencies and there was no investigation. There was an entry which stated, Res (resident) did sit down hard in w/c (wheelchair) one day last week when he almost missed the chair. At the time of discovery, no description of the bruise was documented to assist in determining the age of the bruise and no evidence that staff interviews had been done. g) Resident #25 Review of the facility Concern forms at 10:00 a.m. on 01/14/14, revealed the daughter of Resident #25 had reported a concern to Employee #88 (LPN Supervisor) on Monday, 10/14/13. The daughter visited on Sunday evening (10/13/13) and Resident #25 was wearing the same clothes she was dressed in on Saturday morning (10/12/13) and had no water. The cup in her room was labeled from the 11-7 shift on Saturday night. The facility did not report these concerns as allegations of neglect. There was no evidence of any investigation. e) The Administrator was asked to provide the facility's policies regarding abuse, neglect, and misappropriation and the policies regarding grievances/complaints at 10:00 a.m. on 01/14/14. She responded at 8:50 a.m. on 01/15/14 with the Patient Protection Practice Guide which stated in its opening paragraph, The information included within this guide does not relieve a business unit or center of the obligation to comply with all applicable (name of company) policies as well as federal and state regulations. She was asked if there was a policy instructing staff of who and how to report to in this facility. At 10:50 a.m. on 01/15/14, she provided a one page undated and unsigned paper with the heading Incidents involving any allegation or abuse or neglect must be reported immediately to all of the following and contained a list of agencies. She stated that she was the person ultimately responsible for reporting. The Administrator also provided a one-page instruction sheet, which accompanied the use of the concern form in use and a decision tree. She acknowledged that the decision tree for use with reporting concerns/grievances did not coincide with the decision tree in the abuse/neglect reporting guide. The Administrator stated there was no evidence to show that the facility's review and/or acceptance of these documents and she could locate no facility distinct policies. An interview with the Administrator, Employee #175 (Social Worker), and Employee #77 (Director of Nursing), along with the survey team, was conducted at 11:20 a.m. on 01/15/14, to review the above Concern Forms. The facility provided no additional evidence regarding these occurrences as of the time of exit. The administrator acknowledged that the lack of individualized policies to follow might have resulted in the allegations not being reported. g) Review of personnel files found the facility had not ensured thorough background checks and/or abuse registry checks had been conducted for all employees. These findings were verified on 01/13/14 at 11:00 a.m. by Employee #40, the human resource manager. The following issues were found: 1) Employee #49 The facility had no evidence of statewide criminal background check had been completed for this nurse aide. 2) Employee #15 The facility did not have evidence the abuse registry had been checked for this dietary employee. 3) Employee #122 There was no evidence the abuse registry had been checked for this social worker. 4) Employee #119 No evidence of a statewide criminal background check was found in this housekeeper's file. 5) Employee #187 There was no evidence this nurse had had a statewide criminal background check. h) On 01/21/14 at 1:30 p.m., it was discovered that contracted dietary employees were not included on the employee list. A list of contracted dietary employees was requested. Review of the eight (8) files for these staff found none of them had verification that they did not have findings of abuse, neglect, or misappropriation of funds prior to allowing them to have contact with residents. This was confirmed by administrator, Employee #120 on 01/21/14 at 2:00 p.m. These contracted employees were #177, #178, #179, #180, #181, #182, #183, #184, and #187 (a Registered nurse, 2 Cooks, and 6 Dietary Aides)",2018-05-01
6082,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,226,F,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, personnel file review, and policy review, the facility failed to develop facility specific policies and procedures regarding identification, investigation and reporting of allegations of resident mistreatment, neglect, abuse and misappropriation of resident property. The facility had no facility specific written policies and procedures which included procedures for investigating different types of incidents, identifying the staff member responsible for the initial reporting, reporting of results to the proper authorities, and identifying what constituted an allegation of abuse, neglect, or mistreatment of [REDACTED]. This was found for thirteen (13) of twenty-one (21) employees reviewed (Employees #119, #49, #15, #122, #177, #178, #179, #180, #181, #182, #183, #184, and #187). The residents affected included Residents #50, #148, #111, #47, #27, #71, and #25; however, the practice had the potential to affect all residents. Facility census: 100. Findings include: a) During the survey, seven (7), of forty-three (43) Concern Reports reviewed, which should have been reported to the appropriate State agencies as allegations of neglect or mistreatment of [REDACTED]. In addition, the facility failed to thoroughly investigate the allegations. Affected residents were Residents #50, #148, #111, #47, #27, #71, and #25. Below are the allegations which were not addressed as required: 1) Resident #50 During a care plan meeting on 01/09/14, attended by the resident and a family member, the following allegations of neglect were made: -- The resident's trash can and/or phone were frequently not within reach of the resident. -- The resident was receiving poor nail care. -- The resident stated he gets poor response time to his call light. 2) Resident #148 Resident #148 voiced a complaint of neglect to Employee #80 (Occupational Therapist) at 6:30 a.m. on 12/20/13, when she entered his room. His TED (antiembolitic) hose were on at that time. The resident told the therapist they had been left on for two (2) days and nights, when they were supposed to be taken off at night. He also stated he had asked someone to take them off and they said they would, but did not. 3) Resident #111 A concern form regarding neglect was, Resident (#111) found in bed (sign for 'with') wet sheet, dried brown urine circled on sheets. Resident's hair even saturated (sign for 'with') urine. Resident was cold, wet and shivering. 4) Resident #47 A concern form regarding neglect for this resident noted, Resident voiced that she has not been receiving CPM (continuous passive motion) machine (ordered therapy). The resident reported this to Employee #79 (Occupational Therapist) on 12/22/13, who filed the concern form. 5) Resident #27 On 12/23/13, the resident reported neglect to Employee #88 (LPN Supervisor). The resident said Employee #49 (nurse aide) had not gotten her out of bed until late, had left sheets on her bed that were wet with urine, and had not set up her lunch tray. The resident said she did not want care from that aide again. 6) Resident #71 An injury of unknown origin was reported to staff regarding a skin tear to the right knee and a large bruise on the left lower back of Resident #71 when he was bathed at 12:30 p.m. on 12/03/13. The resident denied any falls and staff documented, Unsure as to exact cause. 7) Resident #25 The family of Resident #25 reported a concern of neglect to Employee #88 (LPN Supervisor) on Monday, 10/14/13. The family visited on Sunday evening (10/13/13) and Resident #25 was wearing the same clothes she was dressed in on Saturday morning (10/12/13). The concern also alleged the resident had no water on Sunday evening. The cup in the resident's room was labeled as provided on the 11-7 shift on Saturday night. 8) Various employees handled the concerns. Employee #116 (RN) had handled several of the concerns. During an interview at 1:00 p.m. on 01/14/14, he stated he assumed the decision had regarding reporting had already been made when he was given the concern to resolve. When asked who was responsible for reporting allegations to the State, his response was Social Services. During an interview with Employee #57 (LPN - Supervisor), at 11:50 p.m. on 01/14/14, she was asked to whom she reported concerns/allegations from the residents. She said she reported them to the director of nurses or the oncoming supervisor. She did not know who reported them to the State. In an interview with Employee #122 (Social Worker), at 09:45 a.m. on 01/14/14, she was asked who was responsible for reporting allegations of abuse/neglect to the State. Her answer was Employee #175 (Social Worker) who was the Patient Advocate. 9 Due to the confusion displayed by front-line employees, at 10:00 a.m. on 01/14/14, the Administrator was asked to provide the facility's policies regarding abuse, neglect, and misappropriation of resident property. She was also asked to provide the policies regarding grievances/complaints. The administrator responded at 8:50 a.m. on 01/15/14, with a commercially printed excerpt entitled: Patient Protection Practice Guide. Its opening paragraph stated, The information included within this guide does not relieve a business unit or center of the obligation to comply with all applicable (name of company) policies as well as federal and state regulations. The guide contained no procedures individualized to the facility. When asked if there was a facility policy which specifically instructed staff to whom and how to report allegations, the administrator stated, I don't think so. At that time, the administrator said she was the person ultimately responsible for reporting. At 10:50 a.m. on 01/15/14, the administrator provided a one (1) page undated and unsigned paper with the heading Incidents involving any allegation or abuse or neglect must be reported immediately to all of the following. The paper contained a list of agencies. The Administrator also provided a one-page instruction sheet which accompanied a decision tree relative to the use of the concern form. She acknowledged the decision tree for use with reporting concerns/grievances did not coincide with the decision tree in the abuse/neglect reporting guide. On 01/15/14 at 10:50 a.m., the Administrator stated there was no evidence to show the facility's review and/or acceptance of these documents. She also stated she was unable to locate facility specific policies. The Administrator said she had called an ad hoc Quality Assurance meeting to address the discovery that the facility had no abuse/neglect policy. An interview was conducted with the Administrator, the Social Worker (Employee #175) and the Director of Nursing (Employee #77) At 11:20 a.m. on 01/15/14. All members of the survey team were present. The concerns which should have been reported and investigated, but were not were discussed. The facility was unable to provide additional evidence for these allegations of neglect. The administrator acknowledged the lack of individualized facility policies might have resulted in the allegations not being reported. b) Employees #119 and #49 Ten (10) personnel files were reviewed on 1/13/14 at 10:00 a.m. The review found the facility failed to obtain statewide criminal background checks for two (2) of the ten (10) records reviewed. This was found for Employee #119 (Housekeeping) and Employee #49 (Nurse Aide). c) Employees #15 and #122 The facility also failed to verify that two (2) prospective employees and eight (8) contracted staff did not have findings of abuse, neglect, or misappropriation of funds prior to allowing them to have contact with residents. This was found for Employee #15 (Nurse Aide) and Employee #122 (Social Worker). During an interview with human resources director, Employee #40 on 01/13/13 at 11:00 a.m., she confirmed the facility failed to screen all potential employees for statewide criminal background or a history of abuse, neglect or mistreating residents as required. d) Contracted Employees #177, #178, #179, #180, #181, #182, #183, #184, and #187 (a Registered nurse, 2 Cooks, and 6 Dietary Aides) On 1/21/14 at 1:30 p.m., it was discovered that contracted dietary employees were not included on the employee list. A list of contracted dietary employees was requested. Review of the eight (8) files for these staff found none of them had verification that they did not have findings of abuse, neglect, or misappropriation of funds prior to allowing them to have contact with residents. This was confirmed by administrator, Employee #120 on 01/21/14 at 2:00 p.m. On the morning of 01/23/14, it was found there were once again additional agency staff working in the building. Information was requested on these three (3) nurses. On 01/23/14 at 1:58 p.m., human resources director, Employee #40 confirmed that for a registered nurse, Employee #187, the facility had no documentation of current license, state wide criminal background check, or verification that she did not have findings of abuse, neglect, or misappropriation of funds prior to allowing her to have contact with residents.",2018-05-01
6083,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,242,E,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, review of snack-related forms provided by the dietitian, review of resident council minutes, resident interviews, and staff interviews, the facility failed to ensure eight (8) of thirty (30) residents interviewed were afforded the right to make choices about aspects of their lives in the facility, which were significant to the residents. Residents voiced reoccurring unresolved concerns regarding the availability and/or the variety of snacks available when the kitchen was closed. Affected residents included Residents #62, #64, #15, #133, #115, #58, #210, and #78; however, the practice had the potential to affect more than an isolated number of other residents. Facility census: 100. Findings include: a) Resident #62 In Stage 1 of the survey, during an interview with Resident #62, at 3:30 p.m. on 01/07/14, she said there were few or no snacks kept on the care unit and if you requested something when the kitchen was not open, you could not get it. She stated this was true for both food and/or drinks. The resident said she had stated this concern during resident council meetings, to the dietitian, at food club meetings, and to the nursing care staff, but nothing had been done. The only answer she had received was from the aide who said the kitchen would not stock snacks on the unit. b) Resident #78 An interview with Resident #78, at 2:00 p.m. on 01/08/14, revealed she agreed there were few, if any, snacks available. She stated, If you want a snack they have to go to the kitchen to get it and you can't get anything when the kitchen is closed in the evening. She added, If you wanted something you should have the physician order [REDACTED]. According to the resident, there was usually juice or tea and crackers kept on the unit, but nothing more. She added that this had been brought up at resident council and she had voiced it to nursing staff and the kitchen staff, but she was told there was nothing they could do. c) Observations of the nourishment kitchen serving the 300/400 halls were made at 8:30 a.m. on 01/08/14; 9:30 a.m. on 01/09/14; 3:00 p.m. on 01/13/14; and 8:15 a.m. on 01/14/14 (on 01/14/14 Employee #87 (Maintenance Director) was present). On each of these observations, there were only graham crackers, soda crackers, and individual containers of peanut butter and jelly found. The refrigerator contained orange juice and a large container of tea. There were never more than four (4) individual containers of milk. There was ice cream in the freezer, but no fruit, puddings, cookies, or bread. d) Observations of the nourishment kitchen serving the 100/200 halls were made at 8:45 a.m. on 1/08/14; 2:00 p.m. on 01/09/14; and 8:15 a.m. on 01/14/14. The only snack items available were graham crackers, soda crackers, and individual containers of jelly and peanut butter. On 01/14/14, there was a partial loaf of bread. The refrigerator contained large containers of sweetened iced tea and orange juice and ice cream. There were no puddings, cookies, or fruits. There was no milk on 01/08/14 or 01/09/14 and only four (4) individual containers of milk on 01/14/14. e) All observations revealed multiple individual containers of ordered supplements labeled for certain residents. There were also cans of soda, provided by purchasing. f) At 9:30 a.m. on 01/14/14, following the earlier observation at 8:15 a.m., both nourishment kitchens were stocked with at least a dozen individual containers of milk, 3 cans of soup, bread, 4 puddings, and a 2 covered bowls of canned fruit. Employee #18 (Aide), who was present, stated this was . a lot more than we usually have. They continued to be stocked throughout the remainder of the survey. g) An additional six (6) resident interviews were completed during Stage 2 of the survey at 8:30 a.m. on 01/16/14. The residents were asked, Can you get a snack in the evening? and What would you like to get?. The responses were: 1) Resident #64: . no snacks unless the kitchen sends them. When asked what she would like to have she said Maybe a sandwich or toast. 2) Resident #15: You get drinks for snacks if you ask for one. He said he would like food. 3) Resident #133: No snacks. The resident said he would like A sandwich. 4) Resident #115: They don't bring snacks. They tell you, 'no extra.' She said she prefers fruit or cookies and milk. 5) Resident #58: They don't keep anything but crackers. She said she would like anything but crackers. 6) Resident #210: You only get a snack if you're a diabetic. The resident said cookies would be nice. All of these residents stated they had questioned staff about snacks, but it had not resulted in them being provided. Some said they just get their family to bring things in. None of the residents had been told why their requests had not been met. h) During an interview with the Senior Consultant Dietitian and Employee #15 (Food Service Supervisor) at 12:50 p.m. on 01/14/14, Employee #15 was asked if she had met with the residents to listen to their concerns/requests regarding snacks. She stated a Food Committee met periodically to discuss issues with the food and she attended these meetings, but she had no authority to promise them snacks. She stated she had forwarded the residents' requests to Administration in the past. i) In an interview with the Administrator, at 8:30 a.m. on 1/24/14, she acknowledged that she was aware of the residents' concerns about the poor amounts and/or variety of snacks available on the units. She could not show any evidence they had discussed or attempted to alleviate the concerns; or had informed the residents of any plans to do so.",2018-05-01
6084,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,244,E,0,1,ZW4411,"Based on resident interviews, staff interviews, and review of resident council meeting minutes, the facility failed to act upon the grievances and recommendations of the resident council in a timely manner. In addition, the facility failed to communicate its decisions to the group. An example was the facility's failure to respond to repeated complaints of slow response by staff to call lights. This had the potential to affect all resident council members, as well as all residents who used call lights to summon assistance. Facility census: 100. Findings include: a) Residents #62, #133, #19, #141, and #78 In interviews, these residents stated they attended Resident Council Meetings. According to the residents, during the meetings, they frequently expressed complaints about the slow answering of call lights. A review of the council meeting minutes from the previous six (6) months revealed concerns addressed about slow response to needs in five (5) of the six (6) months reviewed. In September 2013 and October 2013, the minutes indicated the call light problem was . a little bit better. However, in November 2013, there were again complaints registered. None of the residents interviewed could state what the facility had done to try to solve this problem. b) Resident #62 In an interview with Resident #62, the Resident Council President, at 3:30 p.m. on 01/07/14, she stated the residents at council complained almost every meeting about the staff taking too long to respond to their needs. She added she did not feel the facility was understaffed. The resident said from her room, which was adjacent to the nurses' station, she could hear the aides talking. She said she heard them say such things as, . not me this time and I'm not going in there again. She said she had said this during a council meeting, but did not know if it had been passed on. She said she thought Employee #109 (Activities Director) filled out a separate form and gave it to the social worker and Employee #109 reviewed the complaints at the next meeting. She did not recall anyone talking to the council about the slow response. She said she depended on the Regional Ombudsman to tell her what was being done about the concerns made by the residents. c) During an interview with Employee #109 (Activities Director), at 10:30 a.m. on 01/08/14, she acknowledged she attended all resident council meetings and verified there were usually complaints from the residents about staff being slow to respond to lights. She said these concerns were always relayed to administration via the social worker or director of nurses. She admitted that she did not remember anyone coming to resident council to discuss the concerns with the residents. Employee #109 was not aware of what actions may have been taken. d) Employee #122 (Social Worker) was interviewed at 2:00 p.m. on 01/13/14. She acknowledged she was aware of the residents' complaints that their lights were slow in being answered. She was not sure what action was planned, or if the concern was taken to the Quality Assurance Committee. e) During an interview with the Administrator, Employee #175 (Social Worker), and Employee #77 (Director of Nursing), along with all the survey team, at 11:20 a.m. on 01/15/14, they acknowledged awareness of complaints related to the slow answering of lights and stated action was taken whenever a complaint was made. The Administrator reviewed the minutes of the council meetings and verified there was very little documentation to describe what follow-up was done following a complaint. No additional information to validate any response presented to residents individually or to the resident council was provided prior to exit of the facility.",2018-05-01
6085,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,247,E,0,1,ZW4411,"Based upon resident interview, staff interview, policy review, and record review, the facility had no evidence that notice was given before the resident's room or roommate in the facility was changed. This was found for one (1) of 35 residents reviewed in the Quality Indicator Survey sample, and for three (3) randomly reviewed residents who had room changes in December 2013 or January 2014. Resident identifiers: #58, #109, #148, and #141. Facility census: 100. Findings include: a) Review of facility's policy and procedure for room change notification was on 01/13/14 at 3:00 p.m. The Social Services manual stated Notify patients and responsible parties, as directed, about changes such as room or roommate changes. and Notify the patient or responsible responsible party of the change, the reason for the change, and respond to questions. b) The Social worker (agency), Employee #44, was interviewed on 01/14/14 at 12:19 p.m. She said that social workers do notifications of room/roommate changes when they are aware of them, but the notifications were also done by admissions and by nursing. She was asked where the notification would be documented. She said that social workers document the notification as a progress note in the electronic medical record. She felt that admissions and nursing probably did so as well, but could not say for sure. The Administrator, Employee #120, was interviewed on 01/14/14 at 12:40 p.m. She said she thought there was a form designed for documentation of room/roommate change notification. She was asked to provide a list of room/roommate changes for the past two (2) months. c) The list was provided on 01/14/13 at 1:40 p.m. The Administrator said that although notice of room/roommate changes may have been provided, admissions staff and/or nursing were not always documenting that notice was given. d) Resident #58 said during an interview on 01/07/14 at 10:23 a.m., that she was never notified of a room change in October 2013. Review of the records found no evidence that any notice was ever given. e) Random review of other room changes in December 2013 and January 2014 for residents found the following: 1) Resident #109 was moved on 12/18/14. There was no evidence of notice prior to the move. 2) Resident #148 was moved on 12/04/13. There was no evidence of notice prior to the move. 3) Resident #141 was moved on 12/21/13. There was no evidence of notice prior to the move.",2018-05-01
6086,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,272,D,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the accuracy of the comprehensive assessments for two (2) of thirty-four (34) Stage 2 sample residents. The minimum data set (MDS) assessments completed during Resident #74's stay in the facility did not identify the resident had a pacemaker. Resident #52's urinary continence status was coded incorrectly on the MDS. Resident identifiers: #74 and #52. Facility Census: 100. Findings include: a) Resident #74 Review of this resident's medical record, on 01/14/14 included a review of the admission history and physical, completed by the Medical Director, Employee #102 on 07/18/13. The physician noted under Past Surgical History, the resident had a pacemaker. The cumulative [DIAGNOSES REDACTED]. At no time did the nursing progress notes describe the resident as having a pacemaker throughout his stay at the facility. Both Physical therapy and Occupational therapy notes, dated 10/03/13 and 10/14/13 (a total of four forms), listed pacemaker under the precautions area on the form. The Medical Directory had signed these forms. A review of the Minimum Data Sets (MDS) for Resident #74, along with the Resident Assessment Coordinator, Employee #99, found none of the resident's assessment identified the resident's pacemaker. The MDS Section for Active Diagnoses, I8000, did not have an ICD-9 Code entered to indicate the resident had a pacemaker. Review of the resident's care plan found it did not the resident's pacemaker. In a discussion with the Administrator, Employee #120, on 01/14/14 at 2:00 p.m., she agreed it was problematic. b) Resident #52 A review of the medical record revealed this [AGE] year-old male was admitted to the facility on [DATE]. The resident's admitting [DIAGNOSES REDACTED]. The resident's comprehensive assessment (MDS) on admission indicated he was occasionally incontinent (less than 7 episodes) of urine. The 30 day MDS, with an assessment reference date (ARD) of 09/02/13, indicated he was always continent of urine. The MDS, with an ARD of 10/31/13, indicated he was frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). A review of the progress notes for the assessment period of the quarterly MDS revealed on 10/23/13, 10/24/13, 10/26/13, 10/27/13, 10/2813, and 10/31/13, the nursing staff had documented Resident #52 was continent of bowel and bladder. During an interview, at 11:15 a.m. on 01/14/14, Employee #116 (RN), stated Resident #52 was not incontinent. The nurse reviewed the previous 30 days of task - aide documentation on the electronic medical record and only two (2) incidents of incontinence were entered. The nurse stated the resident was even independent with his toileting. During an interview with Employees #55 and #99 (MDS nurses), at 12:00 noon on 01/14/14, they acknowledged, after reviewing the record, that quarterly MDS was marked in error and should have been marked as 0 as the resident was not incontinent.",2018-05-01
6087,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,278,D,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the assessments for (2) of thirty-four (34) Stage 2 sample residents did not accurately reflect the residents' status. Resident #74's MDS did not identify the resident had a pacemaker. The MDS for Resident #52 did not accurately reflect the resident's continence status. Resident identifiers: #74 and #52. Facility Census: 100 Findings include: a) Resident 74 Medical record review, on 01/14/14, noted the Medical Director had documented the resident had a pacemaker on the resident's admission history and physical which was completed on 07/18/13. The [DIAGNOSES REDACTED]. Nursing progress notes did not describe the resident had a pacemaker throughout his stay at the facility. Both Physical therapy and Occupational therapy notes, dated 10/03/13 and 10/14/13, (a total of four (4) forms) listed pacemaker under the precautions area on the form. Review of the resident's MDS with the Resident Assessment Coordinator, Employee #99, found none of the MDS assessments completed during the resident's stay identified the resident had a pacemaker. In an interview with the Administrator, Employee 120, on 01/14/14 at 2:00 p.m., she agreed it was problematic. b) Resident #52 A review of the medical record revealed this [AGE] year-old male was admitted to the facility on [DATE]. The resident's admission MDS indicated he was occasionally incontinent (less than 7 episodes) of urine. The 30 day MDS, with an assessment reference date of 09/02/13, indicated the resident was always continent of urine. A skilled nursing note written at 01:38 on 10/2/2013, stated: Resident alert and oriented . Communicates all needs effectively.Requires minimal assist from staff for adl's (activities of daily living). Transfers independently. Ambulates with walker with steady gait noted. Continent of bladder and bowel with occasional episodes of incontinence. No s/s of acute distress. Will continue to monitor. Call bell in reach. The quarterly MDS, with an assessment reference date (ARD) of 10/31/13 indicated he was frequently incontinent. A review of the progress notes from the assessment period for the quarterly MDS revealed on 10/23/13, 10/24/13, 10/26/13, 10/27/13, 10/28/13, and 10/31/13, the nursing staff had stated Resident #52 was continent of bowel and bladder. During an interview with Employee #116 (RN), at 11:15 a.m. on 01/14/14, he stated Resident #52 was not incontinent. The nurse reviewed the previous 30 days of task - aide documentation on the electronic record, and only two (2) incidents of incontinence were entered. The nurse stated the resident was even independent with his toileting. During an interview with Employees #55 and #99 (MDS nurses), at 12:00 noon on 01/14/14, they acknowledged, after reviewing the record, that the quarterly MDS was marked in error and should have been marked at 0 as the resident was not incontinent. They had no explanation for the error and stated the nurse who certified the completion and accuracy of the resident's functional status on the MDS was no longer an employee at the facility. Nurse #55 stated she would file a correction to the MDS in question.",2018-05-01
6088,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,279,E,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop a comprehensive care plan with individualized, measurable goals and interventions related to identified needs for eight (8) of thirty-four (34) sample residents and six (6) residents identified through random opportunities for identification during Stage 1 and Stage 2 of the Quality Indicator Survey (QIS) survey. Pacemakers were not addressed for Residents #5, #47, #68, #71, #84, #88, #104, #105, #115, and #134. Behaviors were not addressed for Residents #19, #62, #25, and #57. Resident identifiers: #5, #47, #68, #71, #84, #88, #104, #105, #115, #134, #19, #62, #25, and #57. Facility Census: 100. Findings include: a) Residents #5, #47, #68, #71, #84, #88, #104, #105, #115, and #134 On 01/13/14 at 2:00 p.m., a list was received from Employee #77, the Director of Nursing as requested, of the current residents who had cardiac pacemakers. These residents were on the list. The medical records of these residents were reviewed between 01/04/14 and 01/13/14. It was found all of these resident's care plans had cardiac pacemakers listed as a focus area. The interventions included (typed as written): pacemaker checks as ordered, dated and initiated by the nurse providing care. Further review of each care plan found the care plans did not identify the type of pacemaker, or whether the checks were to be performed within the facility or at a consulting Cardiologist's office. In addition, the care plans did not have individualized goals pertaining to the intervention of pacemaker check . for each resident. An interview was conducted with Employee #99, the Registered Nurse Assessment Coordinator (RNAC) on 01/24/14 at 8:00 a.m. After reviewing the care plans of these ten (10) residents, she commented the nurse who initiated interventions on a resident's care plan was responsible for also providing goals related to the intervention. Employee #99 also confirmed and agreed each of the resident's care plans should contain individualized measurable interventions and goals pertaining to each resident's cardiac pacemaker. b) Resident #19 Review of complaints, concerns, and abuse/neglect reporting began on 01/8/13 at 9:00 a.m. This review was continued and expanded on 01/20/14 as part of extended survey protocol. The review found Resident #19 had thirty (30) documented concerns in 2013 to date. Resident #19's physician had determined the resident possessed the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score, as assessed on 12/17/13, was 15, indicating she was cognitively intact. She was acting as her own decision-maker. Review of her care plan, on 01/16/13 at 1:00 p.m., found she had a focus item for being at risk for changes in behavior problems related to making false accusations towards staff. The goal associated with this item was (typed as written): Will remain free of behavioral disturbances daily thru next review. Interventions implemented toward meeting this goal were (typed as written): 1. Anticipate needs and provide care as able. 2. Provide emotional support as needed. Review of the resident's comprehensive assessments found no indication this resident had behavioral problems. The resident's care plan did not indicate what constituted behavioral disturbances, which rendered it not measurable. The established interventions did not provide guidelines for direct care staff to enable them to provide consistent approaches to the behavior problems. There was no evidence found of what targeted behaviors were to be monitored, which would be needed to determine the effectiveness of the care plan interventions. In an interview with the acting nurse in charge, Employee #124, on 01/21/14 at 3:08 p.m., she was asked to provide any assessments or other documentation regarding behavior concerns for Residents #19. She provided selected nursing progress notes as follows: Progress notes were provided from 01/04/14, 01/09/14, 01/07/14, 01/06/14, 01/10/14, and 01/15/14 regarding the resident's refusal to wear hearing aids. A note, dated 01/12/14, identified the resident had complained to other residents Another resident had his pants down in the hallway and accusing staff of knowing about this and laughing at the situation. The note stated she did not ring call bell or did not come to nurses' station to inform any staff member of this situation. The note concluded the medical director in facility at desk and did not witness this. c) Resident #62 This resident had eleven (11) complaints/concerns/grievances documented. The resident's physician had determined the resident possessed the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score as assessed on 01/09/14 was 15, indicating she was cognitively intact. She was acting as her own decision-maker. This individual was also the current president of the resident council. Review of her care plan, on 01/16/13 at 1:10 p.m., found she had a focus item for being at risk for behavior symptoms related to fabrications of staff refusing care/frequently making accusations toward staff and other residents. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer medications per physician order. 2. Observe for mental status/behavior changes when new medication started or with changes in dosage. 3. Resident refuses psychiatric evaluation. 4. Use consistent approaches when giving care. The resident's comprehensive assessments did not identify this resident had any behavioral problems assessed. The goal was not stated in measurable terms. The only proactive intervention was to use consistent approaches when giving care. There were no guidelines provided to ensure consistent approaches were employed by direct care staff. In an interview with the acting nurse in charge, Employee #124, on 01/21/14 at 3:08 p.m., she was asked to provide any assessments or other documentation regarding behavior concerns Resident #62. She provided selected nursing progress notes as follows: Progress notes were provided from 12/03/13, 12/04/13 and 12/05/13 regarding her complaining of diarrhea, but refusing to provide a specimen. A note from 01/17/14 was provided in which she expressed concern about getting a roommate due to her preferences for cold temperatures and having a lot of personal belongings. d) Resident #25 There were nine (9) documented complaints/concerns/grievances for this resident. The resident's physician had determined this resident possessed the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score as assessed on 10/18/13 was 15, indicating she was cognitively intact. She acted as her own decision-maker during her stay at the facility. Review of her care plan, on 01/16/13 at 1:37 p.m. found she had a focus item for being noted to make false accusations towards staff related to [MEDICAL CONDITIONS]. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer medications per physician order. 2. Observe for mental status/behavior changes when new medication started or with changes in dosage. 3. Use consistent approaches when giving care. The goal was not stated in measurable terms. The only proactive intervention was to use consistent approaches when giving care. There were no guidelines provided to ensure consistent approaches were employed by direct care staff. In an interview with the acting nurse in charge, Employee #124, on 01/21/14 at 3:08 p.m., she was asked to provide any assessments or other documentation regarding behavior concerns Resident #25. She provided selected nursing progress notes as follows: The nurse provided a progress note from 10/18/13 that stated (typed as written), Nurse was standing outside of room passing medications when resident call light came on. Nurse finished passing pills that were already started. Nurse answered call light. Resident states, 'It's about time my call light has been on for an hour.' Nurse explained to resident that she was standing outside of the room when the call light came on but I would be glad to assist her in repositioning. Resident states, 'You are just like everyone else, liars.' Will continue to monitor. She had a progress note dated 10/28/13 that stated: Received phone call at 0310 from residents daughter stating that the resident had called her and said that she couldn ' t reach her call bell and that she was falling out of bed. I told daughter I would go right back and check on resident. Upon entering the room resident found to be lying in the center of the bed and call light was on her left side. Resident states she is not happy about having to call to wake her daughter up. This nurse and CNA repositioned resident in bed and placed her call bell acrossed (sic) her chest at her request. e) Resident #57 Eight (8) complaints/concerns/grievances were documented for this resident. Resident #57 had a recent significant change of condition. Her physician had determined the resident lacked the capacity to make informed medical decisions on 12/27/13, due to illness/early dementia. Prior to that determination, she had acted as her own responsible party throughout her residency in 2013. Her Brief Interview for Mental Status (BIMS) score as assessed on 11/27/13 was 15, indicating she was cognitively intact. Review of her care plan, on 01/16/13 at 1:42 p.m. found she had a focus item for being at risk for behavior symptoms such as making false accusations towards staff and family related to mental illness and [MEDICAL CONDITION]. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer meds per physician orders, observe for effectiveness and side effects such as but not limited to dizziness, drowsiness and falls. 2. If resident exhibits inappropriate behaviors, speak in a soft, calm tone, attempt to redirect, and encourage resident to express herself in a more appropriate manner. 3. Observe for mental status/behavior changes when new medication started or with changes in dosage. 4. Use consistent approaches when giving care. The goal was not stated in measurable terms. There were no guidelines provided to ensure consistent approaches were employed by direct care staff. In an interview with the acting nurse in charge, Employee #124, on 01/21/14 at 3:08 p.m., she was asked to provide any assessments or other documentation regarding behavior concerns Resident #57. She provided selected nursing progress notes as follows: The nurse provided notes regarding behaviors that occurred following the significant change of condition determination that resulted in the physician stating she no longer possessed the capacity to make informed medical decisions. f) Each of these residents had care plan focus items related to being at risk for behaviors due to making false allegations or fabrications. However, none of them had evidence of behaviors documented on their comprehensive minimum data set (MDS) assessments or any other systematic behavior monitoring that would have caused these focus items to be triggered for inclusion in their care plans.",2018-05-01
6089,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,282,D,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, procedure/policy review, and physician interview, the facility failed to provide or arrange services by qualified persons in accordance with the resident's written plan of care. The facility failed to identify Resident #5 had not had a cardiac pacemaker check in over a year. The facility also did not ensure evaluation of the effectiveness of Resident #130's pain medication as directed in his care plan. This was found for two (2) of thirty-four (34) Stage 2 sample residents. Resident identifiers: #5 and #130. Facility census: 100. Findings include: a) Resident #5 On 01/13/14 at 8:45 a.m., medical record review found the resident was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. A review of the care plan noted an intervention of pacemaker check as ordered. Review of the consultation report documentation revealed the resident had pacemaker checks dated 06/6/11, 03/12/12, and 12/11/12. In an interview, on 01/14/14 at 8:30 a.m., with Employee #116, who introduced himself as the Unit Manager (UM) for(NAME)Court, he confirmed Resident #5 had her most recent cardiac pacemaker check in December 2012. He stated the pacemaker check process was to place the physician appointment in the appointment book as recommended by the cardiologist. The consulting cardiologist reviewed his progress notes for Resident #5 and confirmed he had seen her in his office for a cardiac pacemaker check on 12/11/12. Resident #5 was given a return appointment card to be seen again in nine (9) months or sooner if there were any problems. He said her usual schedule was for her to be seen every nine (9) months. He stated she did not return for her scheduled appointment in September 2013. He further commented he was not aware the resident was on Hospice services, . but, either way a patient with a cardiac pacemaker still needs pacemaker checks. The facility had not ensured Resident #5 received checks of her pacemaker function in accordance with the established care plan. b) Resident #130 Review of the resident's medical record, on 01/14/14, noted the resident was admitted to Hospice services on 11/08/13 with a [DIAGNOSES REDACTED]. He had a care plan focus of At risk for pain. with a measurable goal stating Resident will verbalize pain is 0 per resident's pain goal per numeric scale. One (1) of the interventions with a focus on pain stated, Notify physician if pain frequency/intensity is worsening or if current [MEDICATION NAME] regimen has become ineffective. According to the medication administration record (MAR), the resident verbalized he had pain on 01/06/14. He rated his pain as a 4 on a 0 to 10 pain scale on 01/06/14. He was medicated with [MEDICATION NAME] 5/500 1 tablet at 8:30 a.m. by Employee #132, an agency Registered Nurse (RN). At no time on the MAR or in the Nursing Progress Notes was this resident's pain reassessed to determine effectiveness in accordance with the care plan. This information was shared with the Director of Nursing (DON), Employee #77, on 01/16/14 at 11:00 a.m. She said she recognized pain management was a problem in the facility. She provided audits she had completed, but they did not address pain reassessment after medication. She also provided a Pain Practice Guide issued 11/2011 by HCR Healthcare, LLC, which she indicated was the facility policy. On page nine (9) of this guide, it stated Patients are evaluated daily for evidence of pain. (sic) pain evaluation is also completed before and after PRN (as needed) medication administration. The patient's pain scale and score is recorded on the Medication Administration Record (MAR).",2018-05-01
6090,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,371,F,0,1,ZW4411,"Based observation and staff interview, the facility failed to ensure sanitary conditions were maintained in the kitchen. A ceiling vent over a sink was soiled with dust and debris. In addition, beverages stored in the refrigerators on the nursing units were not labeled to identify when they had been opened. This had the potential to affect all residents. Facility census: 100. Findings include: a) During the initial tour of the kitchen, at 2:30 p.m. on 01/06/14, observation of the ceiling vent over the pot-washing sink noted it was laden with dust webs and debris on the cross rails. Observations on a revisit at 11:45 a.m. on 01/09/14, noted it remained in the same condition. Employee #15 (Food Service Supervisor) was advised of this finding at 9:00 a.m. on 01/09/14. She said she would notify maintenance to clean it immediately. b) At 8:30 a.m. on 01/14/14, a tour of the nourishment kitchen on the 100/200 hall unit revealed an opened bulk container of orange juice and one of sweet tea in the refrigerator. Neither of these containers were labeled to identify when they had been opened. During an interview with the Senior Consultant Dietitian and Employee #15 (Food Service Supervisor), at 12:50 p.m. on 01/14/14, they were informed of the unlabeled drinks.",2018-05-01
6091,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,431,E,0,1,ZW4411,"Based on observation and staff interview, the facility failed to provide safe and secure storage of a medication cart. Observations noted an unlocked and unattended medication cart in the 300 hallway. This had the potential to affect more than a limited number of residents. Facility census: 100. Findings include: a) During observation of the 300 hall, at 11:40 a.m. on 01/07/14, the medication cart was unlocked and unattended at the nurses' station. There were no staff members in view of the cart. There were residents in the hall at that time. After a few minutes, Employee #36, Licensed Practical Nurse (LPN) approached the cart. She verified the cart was unlocked. She stated it was the medication cart she was responsible for that day on the 300 hall. In a discussion with the Administrator, on 01/16/14 at 10:00 a.m., she agreed the cart should not have been unlocked and unattended.",2018-05-01
6092,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,441,F,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the spread of disease and infection. Two (2) employees were observed during meal service to have direct contact with a resident and the environment, then serve another resident without performing hand hygiene. The(NAME)Court nourishment kitchen floor was not maintained in a sanitary manner. These issues had the potential to affect all residents. Employee Identifiers: #7 and #66. Resident identifiers: #47 and #58. Findings include: a) Residents #47 and #58 On 01/07/14, observations were made of the lunch service on the 300-400 halls. At 11:50 a.m., Employee #7, Nurse Aide, served Resident #47's lunch tray. She applied a clothing protector to this resident, set up his tray, touched the over-bed table, and left the room. After exiting the room, she removed another tray from the food cart in the hall and served it without performing hand hygiene. At 12:15 p.m., Employee #66, housekeeper, served a tray to Resident #58. She applied a clothing protector to this resident, touched both the over-the-bed table and the bed linens. She then left the room, ran her fingers through her hair with both hands, and removed a tray from the food cart and served it to a resident in room [ROOM NUMBER] without performing hand sanitation. In interviews at that time, both employees stated the policy was to use hand sanitizer between trays and wash their hands every third tray. In an interview, on 01/16/14 at 9:00 a.m., Employee #61, housekeeper, stated housekeeping passes trays often, but not every day. This was confirmed with Employee #6, Environmental Services Supervisor 01/16/14 at 9:30 a.m. She said housekeepers received verbal training on how to set up trays. On 01/16/14 at 10:00 a.m., during an interview with the Administrator, she provided in-service information in which both Employees #7 and #66 had completed courses on hand washing and blood borne pathogens. According to the Annual Mandatory 2013: Infection Control and Prevention in-service from 2013 HCR Healthcare, LLC, It's important to practice hand hygiene upon leaving the patient's room. The Administrator said there should be no infection control concern with housekeepers passing trays, although she acknowledged in this case, there were concerns with the practices of both the nurse aide and the housekeeper. b) On 01/14/14 at 8:30 a.m., observations were made of the(NAME)Court nourishment room floor. There were multiple cracks in the tile. It was soiled. There were large pieces of tile missing from the floor. In a discussion of these findings, at the time of discovery, with Employee #87, Director of Maintenance, he stated he was aware of the tile problems, but had not gotten to it yet.",2018-05-01
6093,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,463,D,0,1,ZW4411,"Based on observation, resident interview, and staff interview, the facility failed to maintain a functioning call system for one (1) of thirty-five (35) Stage 2 sample residents and one (1) randomly observed resident during during Stage 1 of the Quality Indicator Survey (QIS) process. The call lights in the room of Residents #52 and #132 were not functioning. The call lights were adaptive call systems (rubber air bulb style), When the bulb call light was squeezed, it became flat and the call light did not come on to alert staff of the residents' need for assistance. Resident identifier: #132 and #52. Facility census: 100. Findings Include: a) Resident #132 On 01/07/14 at 2:30 p.m., during a room observation for Resident #132, it was discovered that her adaptive (rubber air bulb) call light was not operational and functioning when tested . The bulb became flat when squeezed and did not activate the call light to alert staff the resident needed assistance. The resident commented she was unaware it was not functioning. She said her husband, who was also her roommate, usually turned it on for her since she had vision problems and was legally blind. b) Resident #52 At 2:32 p.m. on 01/07/14, Resident #52's adaptive (rubber air bulb) call light was tested since he was in the same room as Resident #132. Resident #52's call light was not operational and functioning when tested . When the bulb was squeezed to call for assistance, it became flat and the call light did not come on to alert staff. Resident #52 commented the call light was working last night, but was unaware it was not working today. c) Employee #86, a Licensed Practical Nurse (LPN), verified these findings on 01/07/14 at 2:35 p.m. She agreed neither call light was functioning for either resident to call for assistance. d) Employee #116, a Direct Care Delivery/Registered Nurse (DCD/RN) replaced the call system with another adaptive rubber air bulb call light on 01/07/14 at 2:40 p.m. He commented the call system was working last night and the call lights were checked monthly by the Maintenance Department. e) In an interview Employee #87, the Maintenance Director, on 01/10/14 at 8:25 a.m. , he commented random checks were done monthly on five (5) to six (6) rooms on each wing and every three (3) months he checked all the call lights within the facility. He further commented the air bulb call lights would develop cracks in the rubber-like material. Employee #87 said this was the reason the call lights for Residents #132 and #52 malfunctioned during the inspection of the call lights. He explained the adaptive (rubber air bulb) call light had a bulb that deflated when squeezed to turn on the call light system for the residents. Employee #87 also commented the adaptive rubber air bulb call lights should be checked frequently since they developed cracks in the rubber.",2018-05-01
6094,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,465,E,0,1,ZW4411,"Based on observation and staff interview, the facility failed to maintain a safe, sanitary, and comfortable environment. During Stage 1 and Stage 2 of the Quality Indicator Survey (QIS), the hallways and five (5) of forty (40) rooms observed were in need of repairs. Torn pieces of wall coverings hung from the walls in the hallways. There were cracked and uneven tiles on the floor of the hallway leading to the main dining room. Tiles and caulking around toilets were stained and discolored. Plaster walls had cracks, stains, unpainted areas, gouges, and holes. Loose vinyl baseboard and scratched and scuffed doors were also noted. This practice had the potential to affect more than an isolated number of residents. Room numbers: #116, #117, #302, #309, and #400. Facility census: 100. Findings include: a) On 01/13/14, between 2:15 p.m. and 2:45 p.m., a tour of the facility was conducted, accompanied by Employee #87, the Director of Maintenance. The tour revealed the following issues: -- There were torn and hanging pieces of wallpaper-type covering observed on the hallway walls between rooms #403 and #404, #412 and #413, and #410 and #411. -- The entrance to the residents' main dining room had discolored, cracked, and uneven floor tile. -- Room #116 - There was stained and discolored caulking around the base of the toilet. -- Rooms #117 and #302 - The bathroom floors had stained and discolored tile surrounding the base of the toilet. -- Room #309 - The wall behind bed B had scraped areas and gouges in the wall with the unpainted plasterboard visible. There were also holes in the wall measuring 3 x 1, 1 x 1 and 1 x 1. Between the closet door and the bathroom door, the ceiling had cracked plaster, the wall had cracked and stained plaster, and the vinyl baseboard was loose from the wall. The interior portion of the bathroom door was scratched and contained torn jagged wooden type areas half (1/2) way up from the bottom of the door. -- Room #400 - The exterior door to the resident's room was scratched and scuffed. At the completion of the tour, Employee #87 stated he did monthly rounds to view and correct issues such as these. He agreed all of the identified problems needed corrected. He also agreed the entrance to the main dining room and the jagged and torn areas on the interior bathroom door were unsafe. Employee #87 further agreed the issues were not sanitary and did not provide a comfortable environment.",2018-05-01
6095,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,490,F,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, review of facility policies, resident interviews, and staff interviews, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Multiple systems related failures were found with abuse/neglect prohibition, accuracy of information in medical records, maintenance of the physical environment, operationalization and implementation of facility specific policies and procedures, and the establishment of a functional, effective, quality assurance program. These systemic problems had the potential to result in harm to all residents in the facility. Facility census: 100 Findings include: a) Record review, staff interview, and policy review identified the facility failed to clarify and periodically review existing advance directives. Advanced directives were not accurately documented to effectively communicate the resident's choices to the direct care staff should the need to implement, or not implement, cardiopulmonary resuscitation (CPR) arise. This was true for four (4) of thirty-four (34) sample residents. Residents #114, #130, #99, and #5 ' s medical records had conflicting information about whether the individual to be a full code (resuscitated) or was not to be resuscitated. Licensed Practical Nurses, Employees #151, #69, #110, and #52 were asked what they looked at in the medical record to determine the code status. Based on the responses, it would be possible for nurses to look at the Condition Alert tab and find the resident was to be coded, while the physician's order [REDACTED]. The conflicting information found in the medical record and among staff members in regards to code status was discussed with the Administrator, Employee #120 and the Director of Care Delivery, Employee #124, Registered Nurse (RN) on [DATE] at 1:00 p.m. They acknowledged there was conflicting information in the residents' charts. A policy was provided titled Emergency Management code status identification revised ,[DATE]. This policy stated, Review and documentation of new physician orders [REDACTED]. Employee #120 stated a new process was going to be put into place effective immediately due to the breakdown of the current system. b) The facilityfailed to actively seek a resolution to grievances and/or to keep the resident informed of the progress being made. Residents had voiced reoccurring concerns regarding the availability and/or the variety of snacks available when the kitchen was closed; and/or the extended length of time required for care needs to be met for fifteen (15) of thirty (30) residents interviewed. Resident identifiers: #62, #64, #7, #70, #15, #133, #115, #84, #88, #58, #19, #65, #141, #210 and #78. The resident interviews found snacks were not available to residents unless ordered by the physician. Observation of the unit nourishment kitchens found there were usually juice, crackers, tea, 4 individual cartons of milk (usually), and individual packets of peanut butter and jelly. The residents said once the main kitchen was closed, staff could not get them anything else. The residents had voiced this concern in resident council meetings, the Food Club, and to staff members. No resolution had been implemented, and residents had not been provided any information about resolution. The residents had also voiced complaints about staff responses to call lights. Residents #62, #64, #7, #70, #15, #133, #115, #84, #88, #58, #19, #65, and #141 were interviewed and none could state what, if anything had been done to resolve the problem. This issue had been voiced in five (5) of the previous six (6) months resident council meetings. c) The facility failed to identify, report, and thoroughly investigate all allegations of abuse/neglect/mistreatment. Seven (7) of forty-three documented grievances/concerns were not reported to the appropriate State agencies. Additionally, the facility did not have evidence a thorough investigation had been conducted. The facility did not report and conduct a thorough investigation. 1) Resident #50 - the issues were items were not in reach, poor nail care, and poor response to call lights. There was no evidence the allegations of neglect were reported to the appropriate State agencies as required, nor was there evidence the allegations were thoroughly investigated. 2) Resident #148 - the resident complained antiembolitic stockings had been left on for two days and nights and when he asked to have them removed, the person said he/she would, but did not. No one was assigned to investigate this issue. It was not reported to the State agencies as neglect. 3) Resident #111 - the resident ' s sheets were wet with dried brown circles and even her hair was wet. The resident was cold and shivering. There was no documented evidence an investigation had been conducted other than Interviewed LN & CNAS (licensed nurse and certified nursing assistants) caring for resident during shift prior to reported concern. Care provided prior to end of shift and Investigation completed. Care determined to be provided. This was not reported to the State agencies as an allegation of neglect. 4) Resident #47 - complained she had not received therapy the continuous passive machine. This was not reported to the State agencies. 5) Resident #27 - complained Employee #49 (nurse aide) had not gotten her out of bed until late, had left sheets on her bed that were wet with urine, and had not set up her lunch tray. She did not want care from that aide again. This was not reported to the State agencies as neglect. The investigation consisted of a follow-up interview with Resident #17 and interviews with three (3) other residents. One of those residents (Resident #114) had the same complaint about the same aide. 6) Resident 71 - staff found a skin tear to the resident ' s right knee and a large bruise on his left lower back. The cause was unknown. The facility did not report this bruise of unknown origin to the appropriate State agencies and there was no investigation. 7) Resident #25 - the resident ' s daughter reported on a Monday ([DATE]) the resident had the same clothes on that she had worn on Saturday and she had no water. The cup in the resident ' s room was labeled from the ,[DATE] shift on Saturday night. The facility did not report these concerns as allegations of neglect. There was no evidence of any investigation. The Administrator was asked to provide the facility's policies regarding abuse, neglect, and misappropriation and the policies regarding grievances/complaints at 10:00 a.m. on [DATE]. She responded at 8:50 a.m. on [DATE] with the Patient Protection Practice Guide which stated in its opening paragraph, The information included within this guide does not relieve a business unit or center of the obligation to comply with all applicable (name of company) policies as well as federal and state regulations. She was asked if there was a policy instructing staff of who and how to report to in this facility. At 10:50 a.m. on [DATE], she provided a one page undated and unsigned paper with the heading Incidents involving any allegation or abuse or neglect must be reported immediately to all of the following and contained a list of agencies. She stated that she was the person ultimately responsible for reporting. The Administrator also provided a one-page instruction sheet, which accompanied the use of the concern form in use and a decision tree. She acknowledged that the decision tree for use with reporting concerns/grievances did not coincide with the decision tree in the abuse/neglect reporting guide. d) Thirteen (13) of twenty (20) personal files reviewed did not have evidence of criminal background checks and/or evidence the abuse registry had been checked to make sure there were no findings of abuse/neglect/mistreatment for [REDACTED].#49, #15, #122, #119, #177, #178, #179, #180, #181, #182, #183, #184, and #187. f) The facility failed to maintain a safe, sanitary, and comfortable environment. During Stage 1 and Stage 2 of the Quality Indicator Survey (QIS), the hallways and five (5) of forty (40) rooms observed were in need for repairs. Torn pieces of wall coverings hung from the walls in the hallways. There were cracked and uneven tiles on the floor of the hallway leading to the main dining room. Tiles and caulking around toilets were stained and discolored. Plaster walls had cracks, stains, unpainted areas, gouges, and holes. Loose vinyl baseboard, scratched and scuffed doors were also noted. g) The facility failed to ensure the quality assurance program identified issues, implemented corrective actions, and monitored the corrective actions to ensure continued compliance.",2018-05-01
6096,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,492,F,0,1,ZW4411,"Based upon record review and staff interview conducted for each specific citation, the facility failed to operate and provide services in compliance with all applicable State and local laws, regulations, and codes. There were multiple deficient practices cited for failure to comply with West Virginia Nursing Home Licensure Rule 64CSR13. This had the potential to affect all residents. Facility census: 100. Findings include: a) The facility failed to develop and maintain written policies and procedures, and failed to ensure the policies and procedures were effectively operationalized by the facility as required by 64-13-10.3.d. The facility had not implemented policies and procedures regarding the investigation and reporting of allegations of abuse and neglect. b) The facility failed to maintain personnel files containing all required information as required by 64-13-11.6.a-i. Personnel files did not contain reference verifications, signed job descriptions, verification of current licenses, evidence of criminal background checks, evidence the abuse registry had been checked, and/or evaluations of work performance. c) The facility failed to have a written disaster and emergency preparedness plan that had been approved by the director as required by 64-13-9.11.b.",2018-05-01
6097,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,493,F,0,1,ZW4411,"Based upon record review, review of facility policy and procedure, and staff interviews the governing body, and designated administrator, failed to ensure policies regarding the management and operation of the facility were established and implemented. The facility failed to effectively maintain and operationalize policies and procedures. This had the potential to affect all residents. Facility census: 100. Findings include: a) The facility's failure to fully operationalize and maintain effective policies and procedures resulted in deficient practices being cited related to employee screening for abuse prevention. Review of thirteen (13) employees ' personnel files found the files did not contain all State required information, such as signed job descriptions, verification of current license/registration, evidence the nurse aide abuse registry and been checked to make sure the individual was not listed, etc. Three (3) of the thirteen (Employees #40, #119, and #49 did not have evidence of a statewide criminal background check. b) The facility failed to ensure allegations of abuse/neglect were identified, investigated, and reported to the appropriate administrative personnel and State agencies. The facility did not identify the staff member responsible for initiating the reporting process. Seven (7) of forty-three allegations of abuse/neglect were not thoroughly investigated and/or reported. (Resident identifiers: #50, #148, #111, #47, #27, #71, and #25.) c) Following the discovery of the lack of facility specific policies and procedures for abuse/neglect prohibition, a discussion was held with administrator, Employee # 120 on 01/20/14 at 9:00 a.m. She said the corporate owner of the facility had policies and procedures, which were available on the Internet, and these policies and procedures were revised and updated by corporate personnel as needed. There was no evidence that the facility itself had adopted them or that the medical director, administrator, director of nursing, or other department heads had read, reviewed them, and approved them as being appropriate, effective, and representative of what the facility actually does to protect and provide care for residents on a daily basis. d) When asked on 01/22/14 at 11:55 a.m. for documentation that the policies and procedures were maintained and operationalized by periodic review for continued effectiveness, administrator, Employee #120, furnished a Review and approval page from the Laundry Manual. The page consisted of the statement: The Laundry Manual is reviewed and approved to maintain current practices and healthcare industry standards by each of the following center representatives: Administrative Director of Nursing Services, Administrator, Medical Director, Housekeeping/Laundry Supervisor. The most recent dated signature section containing all four (4) signatures was dated 1/21/2010. When asked about other department policies and procedures, the administrator said the laundry review and approval was the most recent one she could find. She said that the corporation had done away with the process of facility management periodically reviewing and approving policies and procedures to ensure they were appropriate and customized for specific facility use because there was no tag for it. e) On 01/22/14 at 3:30 p.m., the Administrator was asked for evidence of a process to ensure that any revisions made to procedures at the corporate level were consistently communicated to the appropriate department manager, that facility management and the department manager evaluated and approved the revisions for adoption as specific facility procedure, and that any changes in daily work assignments and routines were promptly and effectively communicated to line staff responsible for changing the way they were actually carrying them out on a daily basis. On 01/23/14 at 11:00 a.m., evidence was furnished consisting of a regularly scheduled, annual infection control in-service.",2018-05-01
6098,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,496,E,0,1,ZW4411,"Based upon personnel file review and staff interview, the facility failed to ensure it had received registry verification that an individual met competency evaluation requirements before allowing an individual to serve as a nurse aide. This was found for two (2) of twenty (20) personnel records reviewed. This had the potential to affect more than a limited number of residents. Employee Identifiers: #37 and #93. Facility census: 100. Findings include: a) Ten (10) personnel files were reviewed on 01/13/14 at 10:00 a.m. The review found the facility failed to obtain registry verification for Employee #37 to ensure the individual met competency evaluation requirements before allowing the employee to serve as a nurse aide. b) During an interview with human resources director, Employee #40, on 01/13/13 at 11:00 a.m., she confirmed that the facility failed to obtain the required registry verification. c) An additional sample of ten (10) nursing assistants' personnel files was chosen at random to supplement the sample for an extended survey. These records were reviewed for registry verification on 01/20/14 at 1:00 p.m. The review found the facility failed to obtain registry verification that Employee #93 met the competency evaluation requirements before allowing the individual to serve as a nurse aide.",2018-05-01
6099,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,503,C,0,1,ZW4411,"Based on contract review and staff interview, the facility failed to maintain an agreement to obtain laboratory services from a laboratory that meets the applicable requirements. This practice has to potential to affect all residents. Facility census: 100. Findings include: a) On 01/23/14, during a review of contracts the facility had with outside agencies, a contract between a laboratory company and the facility was found. A former administrator had signed the contract, but it was not dated. The laboratory company portion had no signature. In an interview with the Administrator, on 01/23/14 at 10:00 a.m., she verified the facility still used that laboratory for services. She stated she did not have a signed and dated contract between the facility and the laboratory company.",2018-05-01
6100,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,508,D,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, staff interview, and physician interview, the facility failed to ensure the provision of diagnostic services to meet the needs of two (2) of eleven (11) residents with cardiac pacemakers. Resident #5 had a cardiac pacemaker for which the facility did not arrange cardiac pacemaker checks by the consulting cardiologist. Resident #74 was admitted with a pacemaker for which the facility did not determine if there was a need for a pacemaker check during his stay at the facility. Resident identifiers: #5 and #74. Facility Census: 100. Findings include: a) Resident #5 On 01/14/14 at 8:15 a.m., a medical record review was conducted for Resident #5. She was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the care plan found interventions of pacemaker check as ordered. Review of the consultation report documentation revealed the resident had pacemaker checks dated 06/06/11, 03/12/12, and 12/11/12. At 8:20 a.m. on 01/14/14, an interview was attempted with Resident #5. She was not able to be interviewed due to her cognitive status. An interview was conducted with Employee #116, who introduced himself as the Unit Manager (UM) for(NAME)Court on 01/14/14 at 8:30 a.m. During the interview, Employee #116 confirmed Resident #5 had her most recent cardiac pacemaker check in December 2012. He stated the pacemaker check process was to place the physician appointment in the appointment book as recommended by the Cardiologist. At 10:10 a.m. on 01/14/14, Employee#116 provided the requested cardiac pacemaker policy. He commented there was only a telephonic pacemaker policy. During the interview he stated according to the manufacturer's recommendation there was no specific time frame, it was determined by the physician. Employee #116 said usually the residents were seen by their cardiologist every three (3) to six (6) months, or for some it was nine (9) months to a year. He stated the pacemaker check for Resident #5 was overlooked by nursing and the physician. On 01/22/14 at 10:35 a.m., a telephone interview was conducted with the attending physician for Resident #5. The attending physician stated, I was not aware of her not having cardiac pacemaker checks until the 16th (01/16/14) of this month and gave the nurse a verbal order to discontinue pacemaker checks due to the resident's ailing health and being on Hospice. It should be noted, as of 01/14/14, the resident had not had a pacemaker check since 12/11/12. The order for its discontinuation was given after the identification of the facility's failure to ensure pacemaker checks was identified during the survey. A telephone interview was conducted with Resident #5's consulting Cardiologist at 2:30 p.m. on 01/22/14. The consulting Cardiologist stated cardiac pacemakers were checked sometime within a year depending on the type of pacemaker. The cardiologist said when the resident was seen in his office, a progress note or a return appointment card was sent back with the resident to the facility for the next pacemaker check appointment. The consulting Cardiologist reviewed his progress notes for Resident #5 and confirmed she was seen in his office for a cardiac pacemaker check on 12/11/12. Resident #5 was given a return appointment card to be seen again in nine (9) months or sooner if any problems - that was her usual schedule, to be seen every nine (9) months. He stated she did not return for her scheduled appointment in September 2013. He further commented he was not aware the resident was on Hospice services, but Either way a patient with a cardiac pacemaker still needs pacemaker checks. b) Resident #74 Review of this resident's medical record, on 01/14/14, revealed this resident was admitted on [DATE] and was discharged home on[DATE]. The resident's admission history and physical was completed by the Medical Director, Employee #102, on 07/18/13. Under past medical history, it was noted the resident had a pacemaker inserted. The 11/21/13 cumulative [DIAGNOSES REDACTED]. The nursing progress contained nothing which indicated an awareness the resident had a pacemaker. Both Physical therapy and Occupational therapy notes dated 10/03/13 and 10/14/13 (a total of four forms) listed pacemaker under the precautions area on the form. These forms were signed by the Medical Director, Employee #102. The care plan was reviewed. A pacemaker was not addressed for Resident #74. During the resident's stay, the need for pacemaker checks was never addressed by the physician. There was no evidence the facility evaluated if the resident's pacemaker was due for a routine check while he resided in the facility. This was discussed with the Administrator, Employee #120, on 01/14/14 at 2:00 p.m. She agreed it was problematic.",2018-05-01
6101,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,510,E,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility obtained diagnostic tests without a physician's order for nine (9) of nine of thirty-four (34) sample residents whose medical records were reviewed during the Quality Indicator Survey. Nine (9) of nine (9) cardiac pacemaker checks were arranged and performed for residents without a physician's order to do so. Resident identifiers: #47, #68, #71, #84, #88, #104, #105, #115, and #134. Facility Census: 100. Findings include: a) Residents #47, #68, #71, #84, #88, #104, #105, #115, and #134 The care plans for these residents had cardiac pacemakers listed as a focus area. The interventions for each of the residents included (typed as written): Pacemaker checks as ordered. Each was dated and initiated by the nurse providing care. Further review of the medical records confirmed each resident had a cardiac pacemaker. None of the residents had a physician's order for pacemaker checks; however, each resident had a cardiac pacemaker check during 2012 or 2013. On 01/13/14 at 12:25 p.m., an interview was conducted with Employee #124, the Direct Care Delivery (DCD) Registered Nurse (RN) for Nutter Fort and Employee #77, the Director of Nursing (DON). Employee #124 stated, There are no written orders for pacemaker checks. She explained cardiac pacemaker checks were put in the appointment book when they were scheduled, and this was the facility's only means of tracking pacemaker checks for the residents. After a review of the care plans for the nine (9) residents, the RN, Employee #124, said If you want to argue verbiage, it is not correct. This statement was made regarding the care plan interventions which stated, pacemaker checks as ordered. The DON stated she would contact the corporate office regarding the residents not having a physician's order for cardiac pacemaker checks. She agreed it was a standard of practice to have a physician's order for diagnostic tests to be performed. At 1:50 p.m. on 01/13/14, an interview was conducted with the DON, after she contacted the corporate office consultants regarding the pacemaker checks. The DON stated, There is supposed to be a written physician order for [REDACTED]. She further commented, she was now aware the residents had been transported to the cardiologist offices for pacemaker checks without a written physician order. She also agreed the present system, for scheduled cardiac pacemakers checks only being recorded in the appointment book, needed to be re-evaluated to ensure a written physician order was obtained for the diagnostic test.",2018-05-01
6102,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,514,E,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to maintain clinical records that were complete, accurately documented, readily accessible, and systematically organized for six (6) of thirty-four (34) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Code status was conflicting in the medical records for Residents #114, #130, #99, and #5. The medical record contained nursing progress notes in both paper and electronic formats for Residents #130 and #115. The nurse's notes in the medical record of Resident #74 did not note the resident had a pacemaker. There were blanks (no initials) in the medication administration records of Resident #114. Resident identifiers: #114, #130, #99, #5, #74, and #115. Facility census: 100. Findings include: a) Resident #114 Medical record review, on 01/16/14, revealed this resident had a FULL CODE sticker on the condition alert tab in his medical record. A green page in the medical record identified the resident was a Full Code status, as did the physician's orders [REDACTED]. The West Virginia Physician order [REDACTED]. It was marked Do Not Attempt Resuscitation. The POST form was signed by the medical power of attorney on 11/02/13 and by the physician on 12/12/13. b) Resident #130 Resident #130 was admitted to Hospice services on 11/08/13. The medical record contained a copy of a physician's prescription, dated 11/13/13, which stated, Please make patient DNR. A physician's orders [REDACTED]. The condition alert tab identified the resident was a FULL CODE. A green page in the medical record also stated Full Code. A sticker on this page stated Do Not Thin From Chart. In addition, nursing progress notes were found on the electronic medical records for all residents reviewed during the survey. On 01/16/14 handwritten paper nursing notes were found on the medical record. They were written by Employee #134, an Agency Registered Nurse (RN) on 09/06/13, Employee #131, an Agency Licensed Practical Nurse on 12/31/13, and Employee #132, an Agency RN, on 01/06/14. According to the Administrator, in an interview on 01/16/14 at 10:00 a.m., the start dates of these employees respectively were 09/13/13, 11/18/13, and 09/09/13. They still did not have computer access to the clinical record. The start date of Employee #134 was given as 09/13/13, This was after the date of her nursing note on 09/06/13. c) Resident #99 The condition alert tab in the medical record of Resident 99 did not contain the code status of Resident #99. A Medical Power of Attorney, notarized 10/04/13, included, Do Not Resuscitate. The physician's orders [REDACTED]. d) Resident #5 A POST form, signed by the physician on 09/07/13, indicated the resident's code status was Do Not Resuscitate. The physician's orders [REDACTED]. The condition alert tab, which was intended to be a reference, had a sticker stating FULL CODE. e) Staff interviews were held on 01/16/14 at 12:00 p.m. with licensed nurses on duty. Employee #151, an agency Licensed Practical Nurse (LPN), stated in an emergent situation regarding the resident's condition, she relied on the sticker on the Condition Alert tab as a reference. Employee #69, LPN, stated she also referred to the sticker on the Condition Alert tab. Another LPN, Employee #110, stated she looked for a red or green paper in the chart to let her know the code status of a resident and compared it to the POST form. Employee #52, LPN, stated she looked on the Condition Alert tab and compared it to the POST form. The conflicting information found in the medical record, and among staff members, in regards to code status, was discussed with the Administrator, Employee #120 and the Director of Care Delivery, Employee #124, Registered Nurse (RN), on 01/16/14 at 1:00 p.m. They acknowledged there was inaccurate information in the residents' medical records. A policy was provided titled Emergency Management Code Status Identification. This policy, revised November 2013, stated Review and documentation of new physician orders [REDACTED]. Employee 120 stated a new process was going to be put into place effective immediately due to the breakdown of the current system. f) Resident #74 A medical record review was performed on 01/14/14. An admission History and Physical (H&P) was completed for Resident #74 by the Medical Director, Employee #102 on 07/18/13. The H&P identified the resident had a pacemaker inserted under the section titled Past Surgical History. The [DIAGNOSES REDACTED]. The nursing progress notes did not describe the resident had a pacemaker. A review of the Minimum Data Sets (MDS) was completed for Resident #74 along with the Resident Assessment Coordinator, Employee #99. The MDS did not identify the resident's pacemaker. Both Physical therapy and Occupational therapy notes, dated 10/03/13 and 10/14/13, (a total of four (4) forms) listed pacemaker under the precautions area on the form. These forms were signed by the Medical Director, Employee #102. The care plan was reviewed. A pacemaker was not addressed for Resident #74. These lack of documentation regarding the resident's pacemaker was discussed with the Administrator, Employee #120, on 01/14/14 at 2:00 p.m. She agreed it was problematic. g) Resident #115 There were paper nursing notes on the medical record of Resident #115. The notes were written 08/03/13 by Employee #186 an Agency employee, a licensed nurse and on 01/16/14, by Employee #185, an Agency Licensed Practical Nurse. Their start dates were 09/26/13 and 09/10/13. On 01/16/14, the Administrator provided a policy titled Maintenance of Hybrid Health Record. The policy, dated 08/26/09, did not address combining all nursing notes in one form, whether it be paper or electronic; however, it listed several staff members who had permission to approve access to the electronic record for employees to perform their job duties. The Administrator did not provide an explanation regarding why the employees who were hired in 2013 would not have access to all of the medical record if needed. She said there was a problem getting access for Agency Nurses. The administrator said there were times when both nurses working at a nurse's station would be Agency employees. She said it was possible neither nurse would have access to the medical record during their shift, unless they contacted an employee on the other side of the building. The medical record was not systematically organized or readily accessible to all nurses. h) Resident #114 This resident's Medication Administration Record [REDACTED]. The nurse had not signed off as given for the 6:00 a.m. doses of medications on 01/09/14. The medications due at that time were [MEDICATION NAME] 5 milligrams (mg) orally and Tamsulosin 0.4 mg orally. Additionally, pain assessments were not initialed as completed on 01/09/14 and 01/13/14. Employee #124, Director of Care Delivery, was interviewed at 2:00 p.m. on 01/14/14 She said the resident was not out of the building at 6:00 a.m. It was unclear if the resident received his medication, as the medical record was not complete.",2018-05-01
6103,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,520,F,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, staff interviews, record review, facility policy and procedure review, and review of other facility documents, the quality assessment and assurance (QAA) committee failed to identify and/or act upon quality deficiencies within the facility's operations of which it did have (or should have had) knowledge. The QAA Committed failed to implement plans of action to correct identified problems, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. The QAA committee identified area as permanent items on their monthly agenda. Items included on the monthly agenda, which were identified as deficient practices during the survey included abuse/neglect reporting and investigation, complaints, and environmental issues. These quality deficiencies were not effectively addressed, as allegations of neglect and complaints related to resident life in the facility continued to not be identified, investigated, and/or reported as appropriate. In addition, there was no follow-up to prevent recurrence. Environment was also an identified deficit during the survey. There was no evidence the QAA committee effectively addressed this area of concern which had previously been identified by the facility. In addition, the facility failed to recognize the need to obtain physician orders [REDACTED]. These practices had the potential to affect all residents residing in the facility. Findings include: I) The facility failed to develop facility specific policies and procedures regarding identification, investigation and reporting of allegations of resident mistreatment, neglect, abuse and misappropriation of resident property. The facility had no facility specific written policies and procedures which included procedures for investigating different types of incidents, identifying the staff member responsible for the initial reporting, reporting of results to the proper authorities, and identifying what constituted an allegation of abuse, neglect, or mistreatment of [REDACTED]. This was found for thirteen (13) of twenty-one (21) employees reviewed (Employees #119, #49, #15, #122, #177, #178, #179, #180, #181, #182, #183, #184, and #187). The residents affected included Residents #50, #148, #111, #47, #27, #71, and #25; however, the practice had the potential to affect all residents. During the survey, seven (7), of forty-three (43) Concern Reports reviewed, which should have been reported to the appropriate State agencies as allegations of neglect or mistreatment of [REDACTED]. In addition, the facility failed to thoroughly investigate the allegations. Affected residents were Residents #50, #148, #111, #47, #27, #71, and #25. Below are the allegations which were not addressed as required: 1) Resident #50 During a care plan meeting on 01/09/14, attended by the resident and a family member, the following allegations of neglect were made: -- The resident's trash can and/or phone were frequently not within reach of the resident. -- The resident was receiving poor nail care. -- The resident stated he gets poor response time to his call light. 2) Resident #148 Resident #148 voiced a complaint of neglect to Employee #80 (Occupational Therapist) at 6:30 a.m. on 12/20/13, when she entered his room. His TED (antiembolitic) hose were on at that time. The resident told the therapist they had been left on for two (2) days and nights, when they were supposed to be taken off at night. He also stated he had asked someone to take them off and they said they would, but did not. 3) Resident #111 A concern form regarding neglect was, Resident (#111) found in bed (sign for 'with') wet sheet, dried brown urine circled on sheets. Resident's hair even saturated (sign for 'with') urine. Resident was cold, wet and shivering. 4) Resident #47 A concern form regarding neglect for this resident noted, Resident voiced that she has not been receiving CPM (continuous passive motion) machine (ordered therapy). The resident reported this to Employee #79 (Occupational Therapist) on 12/22/13, who filed the concern form. 5) Resident #27 On 12/23/13, the resident reported neglect to Employee #88 (LPN Supervisor). The resident said Employee #49 (nurse aide) had not gotten her out of bed until late, had left sheets on her bed that were wet with urine, and had not set up her lunch tray. The resident said she did not want care from that aide again. 6) Resident #71 An injury of unknown origin was reported to staff regarding a skin tear to the right knee and a large bruise on the left lower back of Resident #71 when he was bathed at 12:30 p.m. on 12/03/13. The resident denied any falls and staff documented, Unsure as to exact cause. 7) Resident #25 The family of Resident #25 reported a concern of neglect to Employee #88 (LPN Supervisor) on Monday, 10/14/13. The family visited on Sunday evening (10/13/13) and Resident #25 was wearing the same clothes she was dressed in on Saturday morning (10/12/13). The concern also alleged the resident had no water on Sunday evening. The cup in the resident's room was labeled as provided on the 11-7 shift on Saturday night. 8) Various employees handled the concerns. Employee #116 (RN) had handled several of the concerns. During an interview at 1:00 p.m. on 01/14/14, he stated he assumed the decision had regarding reporting had already been made when he was given the concern to resolve. When asked who was responsible for reporting allegations to the State, his response was Social Services. During an interview with Employee #57 (LPN - Supervisor), at 11:50 p.m. on 01/14/14, she was asked to whom she reported concerns/allegations from the residents. She said she reported them to the director of nurses or the oncoming supervisor. She did not know who reported them to the State. In an interview with Employee #122 (Social Worker), at 09:45 a.m. on 01/14/14, she was asked who was responsible for reporting allegations of abuse/neglect to the State. Her answer was Employee #175 (Social Worker) who was the Patient Advocate. Due to the confusion displayed by front-line employees, at 10:00 a.m. on 01/14/14, the Administrator was asked to provide the facility's policies regarding abuse, neglect, and misappropriation of resident property. She was also asked to provide the policies regarding grievances/complaints. The administrator responded at 8:50 a.m. on 01/15/14, with a commercially printed excerpt entitled: Patient Protection Practice Guide. Its opening paragraph stated, The information included within this guide does not relieve a business unit or center of the obligation to comply with all applicable (name of company) policies as well as federal and state regulations. The guide contained no procedures individualized to the facility. When asked if there was a facility policy which specifically instructed staff to whom and how to report allegations, the administrator stated, I don't think so. At that time, the administrator said she was the person ultimately responsible for reporting. At 10:50 a.m. on 01/15/14, the administrator provided a one (1) page undated and unsigned paper with the heading Incidents involving any allegation or abuse or neglect must be reported immediately to all of the following. The paper contained a list of agencies. The Administrator also provided a one-page instruction sheet which accompanied a decision tree relative to the use of the concern form. She acknowledged the decision tree for use with reporting concerns/grievances did not coincide with the decision tree in the abuse/neglect reporting guide. On 01/15/14 at 10:50 a.m., the Administrator stated there was no evidence to show the facility's review and/or acceptance of these documents. She also stated she was unable to locate facility specific policies. The Administrator said she had called an ad hoc Quality Assurance meeting to address the discovery that the facility had no abuse/neglect policy. An interview was conducted with the Administrator, the Social Worker (Employee #175) and the Director of Nursing (Employee #77) At 11:20 a.m. on 01/15/14. All members of the survey team were present. The concerns which should have been reported and investigated, but were not were discussed. The facility was unable to provide additional evidence for these allegations of neglect. The administrator acknowledged the lack of individualized facility policies might have resulted in the allegations not being reported. b) Employees #119 and #49 Ten (10) personnel files were reviewed on 1/13/14 at 10:00 a.m. The review found the facility failed to obtain statewide criminal background checks for two (2) of the ten (10) records reviewed. This was found for Employee #119 (Housekeeping) and Employee #49 (Nurse Aide). c) Employees #15 and #122 The facility also failed to verify that two (2) prospective employees and eight (8) contracted staff did not have findings of abuse, neglect, or misappropriation of funds prior to allowing them to have contact with residents. This was found for Employee #15 (Nurse Aide) and Employee #122 (Social Worker). During an interview with human resources director, Employee #40 on 01/13/13 at 11:00 a.m., she confirmed the facility failed to screen all potential employees for statewide criminal background or a history of abuse, neglect or mistreating residents as required. d) Contracted Employees #177, #178, #179, #180, #181, #182, #183, #184, and #187 (a Registered nurse, 2 Cooks, and 6 Dietary Aides) On 1/21/14 at 1:30 p.m., it was discovered that contracted dietary employees were not included on the employee list. A list of contracted dietary employees was requested. Review of the eight (8) files for these staff found none of them had verification that they did not have findings of abuse, neglect, or misappropriation of funds prior to allowing them to have contact with residents. This was confirmed by administrator, Employee #120 on 01/21/14 at 2:00 p.m. On the morning of 01/23/14, it was found there were once again additional agency staff working in the building. Information was requested on these three (3) nurses. On 01/23/14 at 1:58 p.m., human resources director, Employee #40 confirmed that for a registered nurse, Employee #187, the facility had no documentation of current license, state wide criminal background check, or verification that she did not have findings of abuse, neglect, or misappropriation of funds prior to allowing her to have contact with residents. II) The facility failed to ensure all allegations of mistreatment, neglect, injury of unknown origin, or abuse were reported immediately to the appropriate State agencies in accordance with this regulation and with Code of State Rules, Title 64 Series 13 - Nursing Home Licensure Rule for West Virginia. The facility also failed to have evidence all allegations were thoroughly investigated. This was found for seven (7) of forty-three (43) documented grievances/concerns reviewed. Additionally, the facility had not ensured it did not employee individuals who had been found guilty of abuse, neglect, or mistreatment of [REDACTED]. Thirteen (13) of twenty (20) personal files reviewed did not have this information. Employee identifiers: #49, #15, #122, #119, #177, #178, #179, #180, #181, #182, #183, #184, and #187. Resident identifiers: #50, #148, #111, #47, #27, #71, and #25. 1) Resident #50 A review of a Concern Form revealed the son of Resident #50 made the following allegations during the course of a care plan meeting attended by both the resident and his son on 01/09/14: 1. Resident #50's trash can and/or phone were frequently not within the reach of the resident. 2. The resident was receiving poor nail care. 3. Resident #50 stated he gets poor response time to his call light. A written report was completed for each of these allegations on 01/09/14. The concerns were assigned to Employee #116 (RN and Director of Care Delivery) on 01/10/14, to be resolved by 01/15/14. Notices were distributed to All nursing staff in service on 01/10/14, instructing corrective action to be taken regarding the allegations and the following Resolution of Concern was written on the forms and signed by Nurse #116 - At this time, resident et (and) family are satisfied (sign for 'with') actions taken by facility to correct these concerns. Will cont. (continue) ongoing communication (sign for 'with') resident et family to ensure concerns are resolved. There was no evidence the allegations of neglect were reported to the appropriate State agencies as required, nor was there evidence the allegations were thoroughly investigated. 2) Resident #148 Review of a facility Concern Form revealed Resident #148 had voiced a complaint to Employee #80 (Occupational Therapist) at 6:30 a.m. on 12/20/13, when she entered his room. His TED (antiembolitic) hose were on at that time. The resident told the therapist they had been left on for two (2) days and nights, when they were supposed to be taken off at night. He also stated he had asked someone to take them off and they said they would, but did not. An incident report was also filed and the resident's physician was informed. The form was signed by Employee #77 (Director of Nursing), but no one was assigned to take action on this concern. There was a partially completed State Report attached to the Concern form, but there was no evidence the resident's allegation of neglect was either reported to the appropriate State agencies, or that any type of investigation had been made. There was no indication the facility staff had notified the resident of any action taken to ensure this did not reoccur. 3) Resident #111 A concern form, reviewed, at 10:00 a.m. on 01/14/14, included Resident (#111) found in bed (sign for 'with') wet sheet, dried brown urine circled on sheets. Resident's hair even saturated (sign for 'with') urine. Resident was cold, wet and shivering. The date on the form was 12/20/13 at 8:30 a.m., but it did not state who found the resident in that condition. A nurse (no longer at the facility) was assigned the concern for resolution on 12/21/13. There was no other indication of her involvement. A nurse, Employee #124, completed an incident report on 12/20/13, which noted the family was notified. Employee #77 (Director of Nursing) documented Interviewed LN & CNAS (licensed nurse and certified nursing assistants) caring for resident during shift prior to reported concern. Care provided prior to end of shift and Investigation completed. Care determined to be provided. The completion date on the form was 12/22/13. There was no attached evidence of an investigation. There was no evidence this occurrence was recognized as an allegation of neglect and reported to the appropriate State agencies. When questioned about the incident, at 11:15 a.m. on 01/14/14, Employee #77 confirmed there was no additional information filed, although she did say she talked to the nurse who was working at the time of the incident. 4) Resident #47 Review of the facility Concern forms, at 10:00 a.m. on 01/14/14, found a concern form for this resident noted, Resident voiced that she has not been receiving CPM (continuous passive motion) machine (ordered therapy). The resident reported this to Employee #79 (Occupational Therapist) on 12/22/13, who filed the concern form. This allegation of neglect was not reported to the appropriate State agencies and a thorough investigation was not completed. Employee #116 (nurse) was assigned to take action on the concern. The record indicated his determination that the therapy had not been completed on 12/19/14, and Employee #88 (LPN) had confirmed this in a signed statement. Employee #116 indicated he had discovered four (4) missed treatments between 12/19/13 and 12/22/13 and stated in the report that the resident had confirmed the missed treatments. There were no other interviews or information collected. The resolution was education for the staff nurse identified for the single omission on 12/19/14. During an interview with Employee #116 at 1:00 p.m. on 01/14/14, he stated it was given to him as a concern only and he assumed the decision about reporting had already been made. 5) Resident #27 Review of the facility Concern forms, at 10:00 a.m. on 01/14/14, revealed a concern reported to Employee #88 (LPN Supervisor) on 12/23/13, by Resident #27. Resident #27 stated Employee #49 (nurse aide) had not gotten her out of bed until late, had left sheets on her bed that were wet with urine, and had not set up her lunch tray. She did not want care from that aide again. The facility did not recognize this as allegations of neglect and did not report the allegations to the appropriate State agencies. The investigation contained only a follow-up interview with Resident #27 and interviews with three (3) other residents. One (Resident #141) had the same complaint about the same aide. 6) Resident #71 Review of the facility Concern forms at 10:00 a.m. on 01/14/14, revealed staff reported a skin tear to the right knee and a large bruise on the left lower back of Resident #71 when he was bathed at 12:30 p.m. on 12/03/13. The resident denied any falls and staff documented, Unsure as to exact cause. The facility did not report this bruise of unknown origin to the appropriate State agencies and there was no investigation. There was an entry which stated, Res (resident) did sit down hard in w/c (wheelchair) one day last week when he almost missed the chair. At the time of discovery, no description of the bruise was documented to assist in determining the age of the bruise and no evidence that staff interviews had been done. 7) Resident #25 Review of the facility Concern forms at 10:00 a.m. on 01/14/14, revealed the daughter of Resident #25 had reported a concern to Employee #88 (LPN Supervisor) on Monday, 10/14/13. The daughter visited on Sunday evening (10/13/13) and Resident #25 was wearing the same clothes she was dressed in on Saturday morning (10/12/13) and had no water. The cup in her room was labeled from the 11-7 shift on Saturday night. The facility did not report these concerns as allegations of neglect. There was no evidence of any investigation. 8) The Administrator was asked to provide the facility's policies regarding abuse, neglect, and misappropriation and the policies regarding grievances/complaints at 10:00 a.m. on 01/14/14. She responded at 8:50 a.m. on 01/15/14 with the Patient Protection Practice Guide which stated in its opening paragraph, The information included within this guide does not relieve a business unit or center of the obligation to comply with all applicable (name of company) policies as well as federal and state regulations. She was asked if there was a policy instructing staff of who and how to report to in this facility. At 10:50 a.m. on 01/15/14, she provided a one page undated and unsigned paper with the heading Incidents involving any allegation or abuse or neglect must be reported immediately to all of the following and contained a list of agencies. She stated that she was the person ultimately responsible for reporting. The Administrator also provided a one-page instruction sheet, which accompanied the use of the concern form in use and a decision tree. She acknowledged that the decision tree for use with reporting concerns/grievances did not coincide with the decision tree in the abuse/neglect reporting guide. The Administrator stated there was no evidence to show that the facility's review and/or acceptance of these documents and she could locate no facility distinct policies. An interview with the Administrator, Employee #175 (Social Worker), and Employee #77 (Director of Nursing), along with the survey team, was conducted at 11:20 a.m. on 01/15/14, to review the above Concern Forms. The facility provided no additional evidence regarding these occurrences as of the time of exit. The administrator acknowledged that the lack of individualized policies to follow might have resulted in the allegations not being reported. 9) Review of personnel files found the facility had not ensured thorough background checks and/or abuse registry checks had been conducted for all employees. These findings were verified on 01/13/14 at 11:00 a.m. by Employee #40, the human resource manager. The following issues were found: a) Employee #49 The facility had no evidence of statewide criminal background check had been completed for this nurse aide. b) Employee #15 The facility did not have evidence the abuse registry had been checked for this dietary employee. c) Employee #122 There was no evidence the abuse registry had been checked for this social worker. d) Employee #119 No evidence of a statewide criminal background check was found in this housekeeper's file. e) Employee #187 There was no evidence this nurse had had a statewide criminal background check. f) On 01/21/14 at 1:30 p.m., it was discovered that contracted dietary employees were not included on the employee list. A list of contracted dietary employees was requested. Review of the eight (8) files for these staff found none of them had verification that they did not have findings of abuse, neglect, or misappropriation of funds prior to allowing them to have contact with residents. This was confirmed by administrator, Employee #120 on 01/21/14 at 2:00 p.m. These contracted employees were #177, #178, #179, #180, #181, #182, #183, #184, and #187 (a Registered nurse, 2 Cooks, and 6 Dietary Aides) III) The facility failed to actively seek a resolution to grievances and/or to keep the resident informed of the progress being made. Residents had voiced reoccurring concerns regarding the availability and/or the variety of snacks available when the kitchen was closed; and/or the extended length of time required for care needs to be met for fifteen (15) of thirty (30) residents interviewed. Resident identifiers: #62, #64, #7, #70, #15, #133, #115, #84, #88, #58, #19, #65, #141, #210 and #78. 1) Resident #62 During an interview with Resident #62 at 3:30 p.m. on 01/07/14, during Stage 1 of the survey, she said there were few or no snacks kept on the care unit and if you requested something when the kitchen was not open you could not get it. She stated this was true for both food and/or drinks. The resident said she had stated this concern during resident council meetings, to the dietitian, at food club meetings, and to the nursing care staff, but nothing had been done. The only answer she received was from a nursing assistant, who said the kitchen would not stock snacks on the unit. 2) Resident #78 An interview with Resident #78 at 2:00 p.m. on 01/08/14, revealed she agreed there were few, if any, snacks available. She stated, If you want a snack they have to go to the kitchen to get it and you can't get anything when the kitchen is closed in the evening. She added, If you wanted something you should have the physician order [REDACTED]. According to the resident, there was usually juice or tea and crackers kept on the unit, but nothing more. She added that this had been brought up at resident council and she had voiced it to nursing staff and the kitchen staff, but she was told there was nothing they could do. 3) As a result of these interviews, the following observations were made during the survey: Observations of the nourishment kitchen serving the 300/400 halls were made at 8:30 a.m. on 01/08/14; 9:30 a.m. on 01/09/14; 3:00 p.m. on 01/13/14; and 8:15 a.m. on 01/14/14 (on 01/14/14 Employee #87 (Maintenance Director) was present). On each of these observations, there were only graham crackers, soda crackers, and individual containers of peanut butter and jelly found. The refrigerator contained orange juice and a large container of tea. There were never more than four (4) individual containers of milk. There was ice cream in the freezer, but no fruit, puddings, cookies, or bread. 4) Observations of the nourishment kitchen serving the 100/200 halls were made at 8:45 a.m. on 1/08/14; 2:00 p.m. on 01/09/14; and 8:15 a.m. on 01/14/14. The only snack items available were graham crackers, soda crackers, and individual containers of jelly and peanut butter. On 01/14/14, there was a partial loaf of bread. The refrigerator contained large containers of sweetened iced tea and orange juice and ice cream. There were no puddings, cookies, or fruits. There was no milk on 01/08/14 or 01/09/14 and only four (4) individual containers of milk on 01/14/14. 5) All observations revealed multiple individual containers of ordered supplements labeled for certain residents. There were also cans of soda, provided by purchasing. 6) At 9:30 a.m. on 01/14/14, following the earlier observation at 8:15 a.m., both nourishment kitchens were stocked with at least a dozen individual containers of milk, 3 cans of soup, bread, 4 puddings, and a 2 covered bowls of canned fruit. Employee #18 (Aide), who was present, stated this was . a lot more than we usually have. They continued to be stocked throughout the remainder of the survey. 7) An additional six (6) resident interviews were completed during Stage 2 of the survey at 8:30 a.m. on 01/16/14. The residents were asked, Can you get a snack in the evening? and What would you like to get?. The responses were: 1) Resident #64: . no snacks unless the kitchen sends them. When asked what she would like to have she said Maybe a sandwich or toast. 2) Resident #15: You get drinks for snacks if you ask for one. He said he would like food. 3) Resident #133: No snacks. The resident said he would like A sandwich. 4) Resident #115: They don't bring snacks. They tell you, 'no extra.' She said she prefers fruit or cookies and milk. 5) Resident #58: They don't keep anything but crackers. She said she would like anything but crackers. 6) Resident #210: You only get a snack if you're a diabetic. The resident said cookies would be nice. All of these residents stated they had questioned the staff about snacks, but it had not resulted in them being provided. Some said they just get their family to bring things in. None of the residents had been told why their requests had not been met. 8) During an interview with Employee #109 (Activity Director), at 10:30 a.m. on 01/08/14, she was asked to explain some of the items on the Resident Council Minutes form as she attended the meetings. One of the items listed under, Compliments, comments, on 08/15/13, was Snack machine items - Would like switched but they state they cannot change them. She explained that the residents used the snack machine a lot and when asked, added that the residents say there are not a lot of snacks on the floor in the evening. She stated she had forwarded these complaints to the dietary supervisor and administration. She was not aware of any action taken. In an interview with the Registered Dietitians, at 11:35 a.m. on 01/08/14, they acknowledged awareness of the lack of snacks stocked in the nourishment kitchens and stated they had no control over this as the food supplies were provided by contract with a contracted company. The dietitian who did the assessments said, when interviewing residents, she asked them if they wanted a snack and what their preferences were. She then added it to their food order and had the kitchen send them out, but she stated she only did this for the residents who wanted a snack on a daily basis. The Senior Dietitian stated the nourishment kitchens were stocked daily in the afternoon by the kitchen from a written request from the unit nurse and signed for by a nurse when received. She also stated the aides sign out snacks when they are taken from the room and provided a copy of the Nourishment Room Snack Sign Out Log for January 2013. 9) During an observation of the nourishment kitchens at 1:00 p.m. on 01/08/14, the sign out logs were absent. Employees #98, #7, and #142 (aides) stated they were not required to sign out items from the nourishment kitchen. Employees #116 and #106 (Nurses) verified there was no sign out form in use. Employee #116 stated there had been such a form but the practice had only been in effect for about a month and was dropped. 10) The Senior Dietitian provided an order for [REDACTED]. Of the four (4) types of milk, only a few containers of 2% milk were observed. 11) During an interview with Employee #15 (Food Service Supervisor), at 9:00 a.m. on 01/09/14, she acknowledged the use of the sign-out form for snacks but agreed it had not been used. for a long time. She stated the kitchen did not provide soft drinks, except for ginger ale for therapeutic use. She admitted awareness of complaints from time to time from the residents about snacks, but stated there was nothing she could do about it and did not explain. She provided a copy of the HCR ManorCare HS Snack Rotation schedule which listed puddings, cookies, ice cream, peanut butter crackers, pretzels,cheese its, and graham crackers. 12) An evening visit at 11:30 p.m. on 01/14/14, revealed the same snack items (and same amount) present in the nourishment kitchens as on the earlier visit on the same day (9:30 a.m.). Interviews with Employees #28, #37, #164, #32, and #20 (aides) revealed they had delivered the labeled HS (bedtime) snacks, but had not offered any additional snacks and none had been requested by residents. They expressed surprise at the amount of snacks available and stated that there was usually only Jugs of tea and a juice, and crackers. Employees #32 and #20 stated Resident #29, who was yelling out at that time, could be calmed at times by getting her up and giving her a sandwich, but there was never anything to fix a sandwich with. All of them agreed with this and all agreed a sandwich or toast was the most requested snack. The aides reviewed the HS (hour of sleep) Snack list and said it appeared accurate, but all stated, except for graham crackers and ice cream, none of these items were stocked in the nourishment kitchens. 13) During an interview with the Senior Consultant Dietitian and Employee #15 (Food Service Supervisor) at 12:50 p.m. on 01/14/14, Employee #15 was asked if she had met with the residents to listen to their concerns/requests regarding snacks. She stated a Food Committee met periodically to discuss issues with the food and she attended these meetings, but she had no authority to promise them snacks. She stated she had forwarded the residents' requests to Administration in the past. 14) In a (TRUNCATED)",2018-05-01
6104,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2015-05-01,225,D,1,0,4ZJU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and staff interview, the facility failed to conduct a thorough investigation of an unwitnessed fall resulting in a fracture for one (1) of five (5) residents reviewed with a history of recent falls. The facility viewed the incident only as an unusual occurrence, and failed to thoroughly investigate the incident to rule out neglect. In addition, the facility's report to the State agency was not a factual accounting of the situation. Resident identifier: #83. Facility census: 80. Findings include: a) Resident #83 A review of the medical record, at 9:00 a.m. on [DATE], revealed Resident #83 was a [AGE] year-old female admitted to the facility on [DATE], after a hospital stay. An admission note, entered at 7:30 p.m. on [DATE], by Licensed Practical Nurse (LPN) #153, indicated, Patient is oriented 3X (to person, time, and place), Patient is admitted from (name of hospital) [MEDICAL CONDITION] and pneumonia. Has VRE ([MEDICATION NAME] resistant [MEDICATION NAME]) in a wound on her coccyx. Patient can be alert and then just spaces out. An Immediate FAX Reporting of Allegations form was sent to the Nursing Home Program by Social Worker (SW) #6 on [DATE]. It stated, Resident was found on the floor of her room. She was sent to the hospital for evaluation. She was diagnosed with [REDACTED]. She returned to the Center with full weight bearing status. The discharge summary from the hospital did not correlate with the information the SW reported to the State agency. The discharge summary described the injury as a FALL WITH INOPERABLE FRACTURE OF HIP. Nothing in the medical record stated the fracture did not require surgery. Further, the physician's orders [REDACTED]. This did not correlate with a full weight bearing status as submitted to the State by the SW on the immediate reporting of allegations form. There was no information submitted to the State that described the accident, although a nurse's note was entered at 7:35 p.m. on [DATE] by Nurse #14. The nurse noted, This nurse was in resident room to complete nursing admission assessment. Resident was found lying on floor between bed and wall . After placement in bed; resident verbally voiced complaints of pain and states, 'I think I broke my hip.' A review of the Five Day Follow-up report to the State, also filed by SW #6, included a narrative summary of the Outcome/Results of Investigation as follows: Resident fell out of bed resulting in a [MEDICAL CONDITION]. There was no Corrective Action by the facility entered on the report to the State. The complete record of the investigation of the fall was requested from SW #6 at 8:30 a.m. on [DATE], and received shortly after. The following was hand copied verbatim from the investigation report, as the facility would not allow the survey team a photocopy: The resident is a [AGE] year old female with a history of [MEDICAL CONDITION] who was also a [MEDICAL TREATMENT] patient. She was a new admission on [DATE]. The incident occurred when the nurse was out of the room to obtain something in order to complete the assessment. The resident was sent to the hospital for evaluation and sent back. She was found to have an inoperable [MEDICAL CONDITION]. ACTION After a thorough investigation, it was determined that this was an isolated incident that was an unusual occurrence. CONCLUSION After a thorough investigation, it was determined that this was an unusual occurrence. The staff was attempting to do an assessment with this resident. They left the room momentarily to get something and she had fallen when they returned shortly thereafter. The resident was in end stage [MEDICAL CONDITION]. She was sent to the hospital the following day for another medical reason unrelated to the fall. She did not return to the center. She expired at the hospital. The investigation included only one (1) staff interview, with LPN #14, who was one of the two (2) nurses who were caring for the resident immediately prior to the fall. The statement read: I was doing her skin assessment on admission. I sent the other nurse out to get a dressing. Realized that I needed a Q tip to measure the depth. Stepped outside the door to say I needed it. When I went back in she was in the floor. During an interview with the Administrator and SW #6 at 9:00 a.m. on [DATE], the SW acknowledged this was the entire investigation record and that only one (1)interview statement was done. She also said, after review of the record, she had not indicated on the reports sent to the State what had been discovered about how the accident happened and that she had considered it to be an Unusual Occurrence as was entered into the investigation narrative. The Administrator indicated agreement, with a nod, that the investigation should have been more in-depth. The Director of Nurses (DON) and the Administrator were interviewed at 9:35 a.m. on [DATE]. The DON, who also reviewed the record and the investigation report, stated she was not aware of the total contents of the investigation. There was no evidence in the written investigation, or offered verbally by the facility during the survey, that the incident was identified as potential neglect at the time of the occurrence.",2018-05-01
6105,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2015-05-01,309,D,1,0,4ZJU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and staff interview, the facility failed to ensure one (1) of nine (9) sample residents was provided the necessary services to attain the highest practicable physical, mental, and psychosocial well-being. The resident complained of left shoulder pain. The facility delayed getting an X-ray for eight (8) days after the physician ordered it. In addition, the results of the X-ray were not shared with caregivers to ensure they were aware of the resident's needs as indicated by the X-ray. Resident identifier: #82. Facility census 80. Findings include: a) Resident #82 A review of the clinical record for Resident #82, at 9:00 a.m. on 04/28/15, revealed she was an [AGE] year old female admitted to the facility on [DATE]. The resident complained, to Occupational Therapist #42 on 04/08/15, of left shoulder pain from transfers from C.N.A. (nursing assistant) staff. The complaint was referred to the Director of Care Delivery/Registered Nurse #3, who contacted the physician and obtained an order for [REDACTED]. The X-ray was not completed until 04/16/15 and was reported as, intact hardware across a [MEDICAL CONDITION] head; and Modest to moderate [MEDICAL CONDITION] joint disease of the left shoulder. During an interview with Licensed Practical Nurse (LPN) #14, at 11:30 a.m. on 04/26/15, she was asked why the X-ray was delayed eight (8) days. LPN #14 stated she did not know as most X-rays were done by a mobile unit within 24 hours of ordering. This was verified by Registered Nurse/Unit Manager #143 at 11:40 a.m. on 04/26/15. During an interview with the Director of Nursing (DON), at 11:45 a.m. on 04/26/15, she said she had spoken to the Assistant Director of Nursing #3. The original order was missed and a new order was received on 04/16/15. Upon inquiry, the DON confirmed the information received in the X-ray report, about the presence of the hardware, was not conveyed to staff and would be important to convey to caregivers.",2018-05-01
6106,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2015-05-01,387,D,1,0,4ZJU11,"Based on record review and staff interview, the facility failed to ensure one (1) of nine (9) sample residents was seen by either a physician, nurse practitioner, or physician's assistant a minimum of every 60 days as required. Resident identifier: #80 Facility census: 80. Findings include: a) Resident #80 A review of the medical record revealed Resident #80 had been at the facility since 2011. Her attending physician was Physician #150. The record indicated physician visits were made on: 04/30/2014; 07/31/14 (91 days since last seen); 10/17/14 (71 days since last seen); and 12/05/14 (48 days since last seen). Resident #80 had an annual physical on 04/02/2015 (118 days since last seen). During an interview with the Director of Nurses (DON), at 11:00 a.m. on 04/28/15, she was asked to review the record for Resident #80 and verify the dates the resident was seen by a physician since April 2014. She returned at 2:00 p.m. and said she had located only the dates noted above, and could show no other visits by a physician, nurse practitioner, or physician's assistant. When the Director of Nurses (DON) and the Administrator were interviewed at 9:35 a.m. on 04/30/15, they acknowledged the physician had not visited the resident a minimum of every 60 days. The administrator stated she would discuss this with the medical director.",2018-05-01
6107,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2015-05-01,508,D,1,0,4ZJU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and staff interview, the facility failed to ensure timely radiologic services for one (1) of nine (9) sample residents. The resident complained of left shoulder pain. The physician ordered an X-ray; however, the facility delayed getting the X-ray for eight (8) days after the physician ordered it. Resident identifier: #82. Facility census 80. Findings include: a) Resident #82 A review of the clinical record for Resident #82, at 9:00 a.m. on 04/28/15, revealed she was an [AGE] year old female admitted to the facility on [DATE]. The resident complained, to Occupational Therapist #42 on 04/08/15, of left shoulder pain from transfers from C.N.A. (nursing assistant) staff. The complaint was referred to the Director of Care Delivery/Registered Nurse #3, who contacted the physician and obtained an order for [REDACTED]. The X-ray was not completed until eight (8) days later, on 04/16/15. During an interview with Licensed Practical Nurse (LPN) #14, at 11:30 a.m. on 04/26/15, she was asked why the X-ray was delayed eight (8) days. LPN #14 stated she did not know as most X-rays were done by a mobile unit within 24 hours of ordering. This was verified by Registered Nurse/Unit Manager #143 at 11:40 a.m. on 04/26/15. During an interview with the Director of Nursing (DON), at 11:45 a.m. on 04/26/15, she said she had spoken to the Assistant Director of Nursing #3. The original order was missed and a new order was received on 04/16/15.",2018-05-01
6108,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2015-05-01,514,D,1,0,4ZJU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a closed record and staff interview, the facility failed to ensure the clinical record contained an accurate and complete representation of the current condition for one (1) of nine (9) sample residents reviewed. There was no documentation of an assessment of the resident prior to the resident going out of the facility for [MEDICAL TREATMENT] treatment. The resident returned from an emergency visit to the hospital, within the previous 24 hours, where she was diagnosed with [REDACTED]. Resident identifier: #83. Resident census: 80. Findings include: a) Resident #83 A review of the medical record, at 9:00 a.m. on [DATE], revealed Resident #83 was a [AGE] year-old female admitted to the facility on [DATE], after a hospital stay for [DIAGNOSES REDACTED]. A nurse's note, dated [DATE] at 7:35 p.m., by Nurse #14, stated, This nurse was in resident room to complete nursing admission assessment. Resident was found lying on floor between bed and wall. The record revealed Resident #83 was transferred to the hospital at 7:11 p.m. on [DATE], per physician's orders [REDACTED]. An entry at 4:26 a.m. on [DATE] indicated the resident returned from the hospital with a [DIAGNOSES REDACTED]. An entry at 12:01 p.m. on [DATE] stated the resident was seen by the attending physician and new orders were added. There were no further entries in the record until 2:54 p.m. on [DATE], when the facility was informed by the [MEDICAL TREATMENT] unit, located outside of the facility, of the resident's transfer to an acute hospital from the unit for [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. Additional information, verified by the Administrator, stated the resident expired at the hospital. The clinical record contained no evidence of an assessment of the resident's condition at the time of transfer, by the facility nursing staff, prior to transferring the resident to the [MEDICAL TREATMENT] unit. The record also did not contain the time the resident was transferred or the method of transfer to the [MEDICAL TREATMENT] unit. The director of nurses (DON) and the administrator were interviewed at 9:35 a.m. on [DATE]. The DON, who also reviewed the record, acknowledged the absence of the assessment information and other important information regarding the transfer to [MEDICAL TREATMENT] in the record. She said she would see it was entered to complete the record.",2018-05-01
6933,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-10-16,353,F,1,0,TXTJ11,"Based upon record review, review of staffing postings, staffing assignment sheets, nursing schedules, payroll records, assessed care needs, staff interviews, family interviews, and resident interviews, the facility failed to consistently ensure sufficient nursing staff across all shifts to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. This deficient practice had the potential to affect all residents living in the facility. Facility census: 88. Findings include: a) Complaints received by the Office of Health Facility Licensure and Certification (OHFLAC) led to an on site investigation into allegations, including allegations of insufficient staff to provide needed care during some shifts in August, September, and October 2014. These complaints received by OHFLAC identified some specific shifts when staffing was alleged to be insufficient, and review of the facility's complaint files and abuse/neglect reporting files on 10/06/14 at 9:30 a.m., found additional complaints and allegations related to staffing, delays in care, and neglect. Resident, family, and staff interviews during the investigation of these concerns resulted in additional staffing concerns and other specific dates when insufficient staffing was alleged. The following were sampled for detailed investigation: 1) It was alleged on the 08/29/14 day shift, there were only four (4) nursing assistants working in the facility to care for 87 residents. 2) It was alleged on the 09/08/14 day shift, there were only four (4) nursing assistants working in the facility to care for 86 residents. 3) It was alleged on the 10/03/14 night shift, there was only one (1) nursing assistant working in the facility on the Jackson Court wing to care for 42 of the facility's 89 residents. 4) It was alleged on the 10/03/14 night shift there were only two (2) aides working in the facility on the Nutter Fort Court side of the facility to care for 47 of the facility's 89 residents. 5) It was alleged on the 10/11/14 afternoon shift, there were no aides scheduled to work on the Nutter Fort Court side of the facility to care for 49 of the facility's 88 residents. b) Review of staff posting sheets, staffing assignment sheets, nursing schedules, and payroll records confirmed staffing levels were low on some of the shifts identified for a sampled detailed investigation. This review also found there were discrepancies between the postings, staffing sheets, schedules, and actual payroll data. Detail for each date was as follows: 1) Staffing for 08/29/14 08/29/14 day shift: A complaint being investigated reported there were only four (4) nursing assistants in the building on the 7:00 a.m. - 3:00 p.m. day shift Friday, August 29th, the staffing was not posted for the complainant to see, and toileting, meal tray delivery, and response to call lights were not done in a timely manner. A review of the staffing posting furnished by the facility showed nine (9) nursing assistants had originally been documented for the day shift, but this had been lined out and replaced at some point with 5.5 nursing assistants. It was also noted the posting documented there were only two (2) nursing assistants on the night shift. The census was documented as 87. Two (2) different staffing assignment sheets were provided for 08/29/14. The sheets started with the same typed list of scheduled nursing assistants, including both facility employees and outside agency nursing assistants which showed seven (7) aides scheduled to work the entire shift and two (2) scheduled to come in at 11:00 a.m. Both sheets were marked with lines and notes indicating call-offs, time changes, adjustments in assignments, and a note on one of them that mandating had been refused. The two (2) sheets showed completely different arrangements to attempt to cover the schedule. It was noted that both assignment sheets documented only two (2) nursing assistants were working on the 11:00 p.m. - 7:00 a.m. night shift. Payroll records were requested for 08/29/14. They verified one (1) agency aide was paid for working from 7:00 a.m. to 3:00 p.m. on that shift. Another agency aide was paid for working 7:00 a.m. - 2:00 p.m. on that shift, a facility-employed aide was paid for working 10:00 a.m. - 3:00 p.m. on that shift, and a facility-employed aide was paid for working 7:08 a.m. - 3:00 p.m. on that shift. This established there had actually been slightly less than four (4) nursing assistants working the day shift on 08/29/14. The payroll data for night shift verified one (1) facility-employed nursing assistant was paid for working from 11:00 p.m. - 7:00 a.m. on that shift on the Jackson Court side, and another facility-employed aide was paid for working 11:00 p.m. - 7:00 a.m. on the Nutter Fort Court side of the building. 2) Staffing for 09/08/14 09/08/14 day shift: A complaint being investigated reported there were only four (4) nursing assistants in the building on the 7:00 a.m. - 3:00 p.m. day shift Monday, September 8th. A review of the staffing posting furnished by the facility showed eight and a half (8.5) nursing assistants had been documented for the day shift. The census was documented as 86. Three (3) different staffing assignment sheets were provided for 09/08/14. The sheets started with the same typed list of scheduled nursing assistants, including both facility employees and outside agency nursing assistants which showed eight (8) aides scheduled to work the entire shift. All three (3) sheets were marked with lines and notes indicating call-offs, time changes, and adjustments in assignments. Payroll records were requested for 09/08/14. They verified one (1) agency aide was paid for working from 7:00 a.m. to 3:00 p.m. on that shift, another agency aide was paid for working 7:00 a.m. - 3:00 p.m. on that shift, a facility-employed aide was paid for working 7:00 a.m. - 3:00 p.m. on that shift, and a facility-employed aide was paid for working 7:00 a.m. - 3:00 p.m. on that shift. This established there had actually been four (4) nursing assistants working the day shift on 09/08/14. The payroll data for day shift also included hours for two (2) nurses. Their hours on day shift for 09/08/14 were originally coded as follows: A registered nurse's hours covering the entire day shift were originally coded as registered nurse hours. These had been adjusted from the registered nurse account and moved to the nursing assistant account on 10/13/14, the day the request for the payroll data was made. A licensed practical nurse's hours covering the entire day shift were originally coded as licensed practical nurse hours. These had been adjusted from the licensed practical nurse account and moved to the nursing assistant account on 10/13/14, the day the request for the payroll data was made. The staffing assignment sheets listed two (2) other nurses scheduled for both Jackson Court and for Nutter Fort Court. On 10/16/14 at 9:40 a.m., one of the complainants was asked if they were told licensed nurses were working the floor as aides to help cover the assignments for day shift. The complainant said they asked how many aides were working and they were told there were only four (4) aides working. They were not told any nurses were called in to assist with the needed care on the floor. 3) 10/03/14 10/03/14 night shift: Facility complaint files and abuse/neglect reporting documented a resident on the Nutter Fort Court side of the building complained about not being assisted to get out of bed before the day shift began on the early morning of 10/03/14. The facility documented this as a complaint, and also reported it, not as an allegation of neglect for not accommodating the resident's request to be gotten up, but as an allegation of verbal abuse because a nursing assistant allegedly told him they only had two (2) aides for forty-seven (47) residents and did not have time to get him up. Residents #65, #69, and #85 were interviewed multiple days and times throughout the survey, the last times being on 10/15/14 at 1:34 p.m. (Resident #65), 1:47 p.m. (Resident #69), and 2:00 p.m. (Resident #85). They all said there was only one (1) nursing assistant on the Jackson Court side of the facility during night shift on 10/03/14, and there was another night about a month ago when the same aide had worked alone all night. Residents #65 and #69 said one of the nurses was trying to assist the aide with care needs, answering call lights, etc., but this put her behind in providing her nurses' care duties A review of the staffing posting furnished by the facility showed three (3) nursing assistants had been documented for the night shift. The census was documented as 87. Two (2) different staffing assignment sheets were provided for 10/03/14. The sheets both showed for night shift there were two (2) aides assigned to Nutter Fort Court and one (1) aide assigned to Jackson Court. Payroll records were requested for 10/03/14. They verified a facility-employed aide was paid for working 11:00 p.m. - 7:00 a.m. on that shift, and two (2) facility-employed aides were paid for working 11:00 p.m. - 7:00 a.m. on that shift. 4) 10/11/14 10/11/14 afternoon shift: During the survey, some facility staff provided a staffing assignment sheet which indicated no nursing assistants were assigned to work the 3:00 p.m. to 11:00 p.m. shift on the Nutter Fort Court side of the building on Saturday, October 11th. A review of the nursing schedule found no nursing assistants had even been scheduled for the shift. A visit was made to the facility on the afternoon of Saturday, October 11th at 3:35 p.m. Upon arrival, a nursing assistant on the Nutter Fort Court was asked how many aides were working at that time. She said the facility had called her and asked if she could come in. Even though she had worked several extended shifts in a row, she had agreed to come in from 3:00 p.m. until 7:00 p.m. In addition to her, there was a housekeeper, who maintained a valid nursing assistant registration who had agreed to work the shift as an aide. Two (2) licensed practical nurses said they had volunteered to work as aides for the shift. Payroll data was requested for 10/11/14. It verified one facility-employed nursing assistant worked from 3:00 p.m. - 6:57 p.m. during the shift, one (1) licensed practical nurse worked from 3:00 p.m. - 7:00 p.m. on the shift, one (1) licensed practical nurse worked from 3:00 p.m. - 7:34 p.m. on the shift, and one (1) licensed practical nurse worked from 7:00 p.m. - 11:00 p.m. on the shift as a float aide. The housekeeper's hours were not furnished, but she confirmed she was working as an aide with an assignment, she does possess a current registration, and it was reasonable to credit those hours as having been worked to cover the shift. Staff were asked if the scheduling of licensed nurses to work as aides was a common method of providing need coverage. They said it was not customarily done. One (1) staff member said if the surveyor had not been in the facility since 10/06/14 looking at staffing, none of the additional staff would have been there today. c) Review of residents' care needs as assessed by the facility and continuing interviews with residents and staff confirmed that due to a variety of challenges with staff turnover, retention, and availability for deployment, there were shifts when there was not sufficient nursing staff to provide needed care to residents. Pertinent findings included: 1) Residents' care needs, complaints, and accidents:Review of the Resident Census and Condition of Residents report (CMS-672) completed by the facility upon entrance found there were: -- fifteen (15) residents who were totally dependent upon two (2) or more staff for transfers with a mechanical lift. Ten (10) residents were on Nutter Fort Court and five (5) were on Jackson Court. -- There were also fifty-one (51) residents listed as requiring assistance of one (1) to two (2) staff for transfers. -- Thirty-eight (38) residents were totally dependent on staff for bathing. Twenty-four (24) were on Nutter Fort Court and fourteen (14) were on Jackson Court. -- There were also forty-six (46) residents listed as requiring assistance of one (1) or two (2) staff for bathing. -- Eight (8) residents were totally dependent for toileting. Seven (7) were on Nutter Fort Court and one (1) was on Jackson Court. -- There were also seventy (70) residents listed as requiring the assistance of one (1) or two (2) staff for toileting.Review of shower schedules for 10/13/14 - 10/18/14 found for Nutter Fort Court an average of ten (10) showers on day shift and seven (7) on evening shift. For Jackson Court, there was an average of seven (7) showers on day shift and five (5) on afternoon shift. Based upon these documented care needs provided by the facility, it would not be possible to provide all needed care to residents requiring assistance of one (1) or two (2), and those who were totally dependent, in a timely manner as well as answer call lights, monitor assigned residents and perform all the other duties of a nursing assistant with two (2) nursing assistants on a wing for day shift or afternoon shift, and with one (1) nursing assistant on a wing during the night shift.Review found there were twenty-five (25) documented complaints in the last three (3) months regarding staffing, call light response, or delays in care and treatment. There were sixty-one (61) unwitnessed falls during the last three (3) months. 2) Resident and family interviews: Interviews were conducted throughout the survey. Two (2) family members requested confidentiality stating they were concerned about what would happen should the facility learn what they had to say. A family member interviewed on 10/08/14 at 11:35 a.m. said he/she was concerned there was not sufficient staff to monitor residents who were at risk for falls. His/her loved one had suffered multiple falls which were not witnessed. He/she said his/her loved one often had to wait a long time for help, especially with toileting, and he/she thought that may be the reason for some falls, when the residents tried to get up and go to the bathroom on their own.A family member was interviewed on 10/14/14 at 11:40 a.m. The family member said he/she was concerned about his/her loved one falling because there was not enough staff to check on the residents as much as they should. He/she said staffing was bad, especially on weekends and he/she felt it was affecting resident care and safety. Resident #65 was determined by her physician to possess the capacity to make informed medical decisions on 09/22/12. Her Brief Interview for Mental Status (BIMS) score as assessed on 7/23/14 was 15, which would indicate she was cognitively intact. She was interviewed multiple times during the survey, the last time being on 10/15/14 at 1:34 p.m. She lived on the Jackson Court wing. She said staffing was a big problem, especially on nights and weekends. She often had to wait a long time for assistance, and she was not able to transfer and do a lot of other things for herself. She felt she was being neglected.Resident #69 was determined by the facility as interviewable. Her Brief Interview for Mental Status (BIMS) score as assessed on 08/12/14 was 15, which would indicate she was cognitively intact. She was interviewed multiple times throughout the survey, the last time being on 10/15/14 at 1:47. She lived on the Jackson Court wing. She said many evenings and nights call lights went unanswered and care was done late if it was done at all. She said there have been a couple of nights in the last month when there was only one (1) nursing assistant trying to take care of the entire wing. She said just recently one (1) of the nurses was trying to help the aide answer lights and assist with needed care, but she got behind in her own work by doing it. She said her roommate fell on a Friday night and no one came to help her for a long time, and she was not able to help due to her own dependence on staff for transfers and other care needs. Resident #85 was determined by her physician to possess the capacity to make informed medical decisions and acted as her own responsible party. Her Brief Interview for Mental Status (BIMS) score as assessed on 08/29/14 was 15, which indicated she was cognitively intact. She was interviewed multiple times during the survey, the last time being 10/05/14 at 2:00 p.m. She lived on the Jackson court wing. She also said there had recently been two (2) occasions when there was only one (1) nursing assistant to care for the entire wing at night. She said there had been times when there were only two (2) nursing assistants on the wing for day shift and evening shift, and there was just no way they could do it. She said the same staff had to work over and cover absences all the time, and they got tired and even got sick. She said staff were leaving because they were tired of the staffing problems. She said when surveyors were in the building they did everything they could to make sure there was enough staff, but once they left, it was just the same as it was before.Resident #30 was determined by her physician to possess the capacity to make informed medical decisions on 02/23/14. Her Brief Interview for Mental Status (BIMS) score as assessed on 09/16/14 was 14, which indicated she was cognitively intact. She was interviewed on 10/15/14 at 2:42 p.m. She lived on the Nutter Fort Court wing of the facility. She had made a complaint, which resulted in an immediate reporting of an allegation of neglect, which was completed, on 07/17/14. Resident #30 said she had rung her call bell for assistance to be toileted, but no one came and she ended up completely soaked. The investigation concluded the allegation could not be substantiated, but did note that the documentation on the night shift did not reflect that the care had actually been provided. The nursing assistant was subsequently disciplined for not documenting they had provided the care. The resident said it was no better now than it was then. She often had to wait for help until she had been incontinent. She said she complains, but they do not do anything. She said they just do not make sure there are enough people working. Not just nights or weekends, although they were the worst, but even day shift through the week sometimes they were very short. She said its not just call-offs; They just don't schedule enough people. 3) Direct care staff interviews:Nursing assistants #1, #2, and #3 were interviewed between 5:30 a.m. and 7:00 a.m. on 10/08/14. They said there were often times when there were only two (2) aides on a wing on night shift. There have been times when there was only one (1). They did not feel there was any way the residents could receive the care they need with staffing at those levels.Nursing assistant (NA) #4 was interviewed on 10/08/14 at 1:40 p.m. The NA said he/she work mostly 3:00 p.m. - 11:00 p.m. shift, but often come in early or stay late and work twelve (12) hours. He/she said he/she had worked twelve (12) to sixteen (16) hours for eight (8) or nine (9) days in a row and still got called on his/her day off to come in to cover for low staffing. The same people were mandated to stay over and over again. Those aides got tired; they even got dehydrated and got sick. Some have had to go to the hospital. He/she said when you have been here five (5) years you can refuse to be mandated to stay and cover for missing staff, so the newer staff had to do it all the time. There were only just a few nurses that would try to help with things when the staffing was low. The newer aides were all quitting because they were fed up.NA #5 was interviewed on 10/09/14 at 3:07 p.m. The NA said he/she had been mandated for seven (7) to eight (8) days straight. He/she said last weekend even with mandating there were only two (2) aides for at least part of the evening shift. Even the kitchen staff and the housekeepers tried to help with passing trays and answering call lights. They said there were only a few agency-nursing assistants available now, while there used to be a lot of them. They said they would no longer come to the facility because of the way they were treated. NA #6 was interviewed on 10/09/14 at 3:58 p.m. The NA said there were many times when there were only two (2) aides on a wing during evening shift. The NA said, Its not so much call-offs; they just don't schedule enough staff. He/she said the weekends were the worst. Most nurses would not help, and when there were eight (8) to ten (10) showers to be done with two (2) aides, the care just could not be done. The NA also said agency staff would not come any more because of the workload and the treatment. He/she said, When surveyors are here there are plenty of staff and plenty of snacks and when you leave they don't care.NA #7 was interviewed on 10/13/14 at 5:32 a.m. The NA said he/she had been the only aide on Jackson Court a couple of times in the past month. He/she said one of the nurses tried to help with the care.NAs #8 and #9 were interviewed on 10/13/14 at 6:00 a.m. They said when there were allegations of neglect, and care had not been documented in the computer by the aide, the facility said the allegations were not substantiated because the care was provided and then disciplined the aide for not putting it in the computer that care was done. They said when nurses try to call management on-call, they never get any help from them. They either do not answer or refuse to come in and help.Licensed Nurse #1 was interviewed on 10/08/14 at 3:38 p.m. The nurse said the only thing he/she could say was, They need to staff this place better.Licensed Nurse #2 was interviewed on 10/14/14 at 2:42 p.m. The nurse said there have certainly been days when there was just not enough staff to provide basic care. He/she said staffing with nurses working as aides as had been done just recently does not routinely happen. Some nurses tried to help, but then their medications and treatments would get late. The nurse said they can get no help from management. They do not even bother to call any more, they just do the best they can.Licensed Nurse #3 was interviewed on 10/14/14 at 3:03 p.m. The nurse said he/she had been called to come in on night shift over the weekend and when he/she got to the facility, was told he/she would be working as an aide. The nurse said there had been two (2) Friday nights recently when there was just one aide and the nurses on the wing. He/she said nurses had never been assigned to work as aides to cover shifts until the surveyors showed up.Licensed nurse #4 was interviewed on 10/14/14 at 4:00 p.m. The nurse said he/she always tried to help with the care on the floor when nursing assistant staffing was very low. He/she said many aides have left to work at the newly opened mental health facility in the area, and that had caused difficulty in covering the schedule consistently.4) Management and support staff interviews:The staffing and scheduling coordinator was interviewed on 10/07/14 at 12:42 p.m. She was asked about the staffing assignment sheets, schedules, and staff posting sheets, and why there were sometimes multiple copies with different numbers, names, and hours entered. She said in the current situation it was very confusing and hard to reconcile. The staffing assignments sheets and the schedule were often changed many times, even right up to the beginning of a shift. There were some shifts that started off with few or even no one scheduled and got filled in as best as possible by the time the shift started. She said there had been a high turnover and lots of call-offs. The same people tended to stay over to cover multiple shifts and they got tired.The human resources director was initially interviewed on 10/13/14 at 1:00 p.m. There was a discussion of staffing issues and challenges. She provided information over the next two (2) days showing some of the concerns and efforts being made to address them. She said turnover in the nursing department was a big concern. She provided staff turnover statistics covering 01/01/14 to the present that showed the following: -- Twenty-seven (27) nursing assistants had been hired and thirty-five (35) had resigned or been terminated. -- Five (5) registered nurses had been hired and five (5) had resigned or been terminated. -- Four (4) licensed practical nurses had been hired and eight (8) had resigned or been terminated.She provided a listing of currently available contracted agency nursing assistants, which included six (6) nursing assistants from two (2) staffing agencies. The listing of available contracted nursing assistants from November 2013 included thirty-five (35) nursing assistants from three (3) staffing agencies.She was asked about current procedures for mandating aides to stay over at the end of their shift to cover the next shifts. She said nursing assistants employed by the facility for five (5) years or more could not be made to stay past their scheduled quitting time unless they did so voluntarily. Therefore, nursing assistants who were more recently hired were mandated to stay when staffing levels could not be maintained on the incoming shifts.She was asked about the statement noted on some of the staffing assignment sheets that said Do not pull aides unless 2 call-offs. Can pull agency. She clarified the current procedure was that nursing assistants could not be moved from Jackson Court wing to Nutter Fort wing or vice versa to balance the deployment of available staff unless there had been two (2) call-offs on the wing. If there were two (2) aide positions not covered because there were none available or none scheduled, the assignments may not be balanced between the wings. This had resulted in situations as found on night shift when there could be three (3) aides on one wing and only one (1) on the other.She provided information about a newly established recruitment and retention committee charged with creating and implementing a recruitment and retention plan of action. The composition of the committee was to include shorter and longer service employees, with representatives from each shift and department, and at least 50% should be level one employees. Some of the activities for October 2014 directly related to staffing were to contact area high schools, tech centers, and colleges to set up face to face meetings, implementation of sign on bonuses for nursing assistants and nurses, review of old applications with follow up contacts to let them know about current opportunities, help wanted ads to run in newspapers and on Craigslist, and various staff recognition efforts.She was asked about the on-call schedule for registered nurses. She said there was a rotation among the registered nurses so they would know when they were assigned to be available for call in case of emergencies or staffing problems. She was asked to provide that current schedule. This document was not provided as of the time of the exit conference. Information was also requested for any previous instances of licensed nurses working as aides, with their own assignment as verified by payroll data, as opposed to trying to help out, but still retaining full responsibility for the nurses' duties on the shift. No further payroll information was provided to demonstrate any other past practice of utilizing nurses in this mannerThe administrator was interviewed on 10/14/14 at 9:47 a.m. Findings concerning staffing issues were discussed. It was explained to her that doing a detailed review of payroll data for every shift of every day for the past three (3) months was not feasible, and a sample of dates and shifts had been chosen from concerns identified through complaints and interviews. She was asked about the registered nurses on-call schedule. She said with the turnover in registered nurses and the current vacancies, the acting/interim director of nursing had been the only on call registered nurse for some time, going back to late August or September 2014. She was aware there had been occasions when she was not always available to take call. She was asked if any earlier documented instances had been found when licensed nurses were scheduled to work exclusively as aides to cover critical shortages. She said there had been none except those already documented and discussed. She agreed maintaining adequate staff had been challenging in the last few months. She said there had been attempts to cover that were successful and some instances when they were not. She said two (2) nursing assistants on a wing for day shift or evening shift, or one (1) nursing assistant on a wing at night was not enough to get the job done.",2017-10-01
6934,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-10-16,356,F,1,0,TXTJ11,"Based upon observation, staff interview, and interviews with complainants, the facility failed to post the nurse staffing information on a daily basis at the beginning of each shift. The facility name, the current date, resident census, and the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: 1. Registered nurses. 2. Licensed practical nurses or licensed vocational nurses. 3. Certified nurse aides.This deficient practice had the potential to affect all residents, family members, and visitors to the facility. Facility census: 88. Findings include: a) Entry for the investigation of three (3) anonymous complaints was on Monday, 10/6/14 at 9:00 a.m. Review of the daily staffing postings immediately upon entering the facility found the posted staffing was for Friday, October 3, 2014. Behind that posting were found partially completed daily staffing sheets for Saturday, October 4, 2014, Sunday, October 5, 2014, and Monday, October 6, 2014. During these observations, introductions were made to the administrator. Copies of the daily staffing posting sheets were requested and provided. The administrator agreed the most recent daily staffing sheet posted in the facility was for 10/3/14.b) Upon entry on Saturday, 10/11/14 at 3:30 p.m., the staffing posting was for Friday, 10/10/14. The manager on duty, the patient liaison, confirmed the staffing information posted had not been updated and posted for Saturday, 10/11/14. Upon review of the staffing levels on each wing, it was found the staffing listed on the posting was incorrect. It listed seven (7) nursing assistants for the afternoon 3:00 p.m. - 11:00 p.m. shift. Actual staffing was found to be five (5). c) An anonymous complaint being investigated during the survey alleged the staffing posting for 09/08/14 was not correct. Investigation found the posting for that date documented 8.5 nursing assistants for day 7:00 a.m. - 3:00 p.m. shift. Actual staffing was found to be four (4) nursing assistants. Payroll data was reviewed that indicated two (2) licensed nurses may have been working as aides on the shift, but this would still account for only six (6) staff working as nursing assistants.d) During an interview on 10/14/14 at 9:47 a.m., the administrator acknowledged the postings were not always current and/or accurate. .",2017-10-01
7170,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-07-23,309,D,1,0,J4C611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and medical record review, the facility failed to ensure one (1) of five (5) residents, who received scheduled doses of insulin and sliding scale insulin for diabetes mellitus, received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. A nurse failed to immediately assess a resident after the resident told the nurse she was going to pass out as a result of low blood sugar. Resident identifier: #83. Facility census: 88. Findings include: a) Resident #83 This resident, who had capacity to make medical decisions and a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact, was interviewed at 12:30 p.m. on 07/21/14. According to the resident, she told a licensed practical nurse, Employee #64, she was was going to pass out and she needed help on the evening of 06/19/14. The resident said the nurse never came to check on her and she was in a coma, for several hours. The resident explained that she did her own blood glucose monitoring. She had her own meter and test strips which she kept in her room. She said she tells nursing staff what the reading is and they can also look at the meter which stores the past several readings. She said she was unable to obtain her blood glucose level when she felt she was going to pass out. Review of the medical record found the resident had a [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. If the blood sugar was below 60 or above 400, the physician was to be notified. Blood sugars were to be obtained at 12:00 a.m., 6:00 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m. The resident had a physician's orders [REDACTED]. The medical record contained a nurse's note written by Employee #64 at 3:43 a.m. on the night of 06/20/14 noting, Residents blood sugar at 2030 (8:15 p.m. on 06/19/14) was 130. Scheduled [MEDICATION NAME]20 units given per MD orders. Resident called up to desk at around 2115 (9:15 p.m. on 06/19/14). States she needed someone to bring her something to eat because she was going to pass out. CNA (certified nursing assistant), (name of assistant) was setting at desk charting in POC (the facility's electronic medical record). Asked her to take her grapes and some ice cream and to find out if she wanted anything else. CNA immediately got up and took snack to resident. No report of anything abnormal with resident. Further review of the medical record found no evidence the resident was assessed to determine if she required medical interventions related to her diabetes mellitus and/or other causes, when she stated she felt as though she was going to pass out and asked for help. The next nurse's note was written at 4:05 p.m. on 06/24/14, more than 18 hours after the resident complained of feeling like she was going to pass out. At that time, the resident's vital signs were obtained and her blood sugar was 162. Vital signs were as follows: blood pressure 128/64, pulse 69, respirations 18 and oxygen saturation was 97%. At 9:30 a.m. on 07/22/14, the nurse on duty at the time of the incident, Employee #64, was interviewed. This employee confirmed she did not go check on the resident when she called the nurses' station to report she was going to pass out. She said she sent the nursing assistant to the resident's room with some food. The nurse commented, I realize now I should have went to check on her myself. She stated the resident would frequently say she was going to pass out to get special food items and she figured this was just a tactic for her to get something to eat. She further explained the resident used her own telephone to call the nurses' station instead of putting on her call light. This is her usual way she asks for assistance. Employee #75, the nursing assistant (NA) who provided the resident's snack, was interviewed on 07/22/14 at 4:00 p.m. She said she took the resident ice cream and orange juice around 9:00 p.m. to 9:30 p.m. I stayed with her while she ate the ice cream and she took a couple of sips of the juice. The NA said the resident ate the ice cream, she said she still felt a little shaky so the NA told the nurse, Employee #64. The NA said, I don't know what she did about the situation. I did see the resident up in her power chair before I left the facility at 11:00 p.m., she seemed fine. The NA said she thought the resident was up in the power chair because she was looking for the evening shift supervisor. Employee #75 added, I am a diabetic myself, so I wouldn't have left her until I was sure she was OK. The director of nursing (DON) was interviewed at 9:00 a.m. on 07/23/14. She stated the facility became aware of the resident's accusations and reported the incident to the proper State authorities on 07/20/14. (The DON provided verification of such action.) She stated the facility was unable to substantiate the resident was in a coma, but the nurse was disciplined for her failure to assess the resident. The DON stated that as a result of this incident other nurses were educated about assessing residents with reported changes in condition. She stated nurses' notes will be audited in the future to ensure this action does not happen again.",2017-07-01
7810,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2012-06-08,159,E,0,1,U80L11,"Based on interviews and review of facility practice, the facility failed to ensure same-day access to personal funds for 5 (#s 56, 69, 75, 99, 124) of 10 residents interviewed who had a personal funds account with the facility. Findings include: Five residents (#s 56, 69, 75, 99, 124) interviewed on June 4, 2012, stated that they did not have access to their personal funds account when they need it, including on weekends. An interview was conducted with the Business Office Manager (staff #83) on June 8, 2012. Staff stated that residents have access to their personal funds Monday through Friday from 7:30 am to 5:00 pm. Residents can access their personal funds by requesting a withdrawl from the receptionist. If the receptionist has gone home for the day, residents would have to wait until 7:30 am the next morning. Residents have access to their personal funds on weekends through a manager with access to a petty cash locked box only 8 hours a day. An interview was conducted with the Administrator on June 8, 2012. The Administrator confirmed that the above procedures are currently in place and accurately described. The policy and procedure of the facility regarding personal funds was reviewed. The policy states that the facility should maintain a RPTF (Resident Personal Trust Fund) Petty Cash Fund to enable the facility to meet resident's request of a cash withdrawl.",2017-01-01
7811,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2012-06-08,247,D,0,1,U80L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility practice the facility failed to notify residents of room changes or roommate changes. This involved 2 of 4 residents investigated out of the 24 residents interviewed regarding room changes, (#54 and #172). Findings include: 1. Review of the medical record for Resident #54 revealed an original admission date of [DATE] and the most current admission date of [DATE]. The medical record revealed [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE], a comprehensive assessment revealed Resident #54 was assessed to be able to make herself understood and able to understand others. The MDS also indicated Resident #54 scored a 13 of 15 on the Brief Interview for Mental Status (BIMS). Review of a document titled Notification of Room/ Roommate Change revealed areas for staff to document if the resident was informed of a new roommate and areas for any comments. Review of a form titled Regulation and Role Table, dated June 2012 revealed the social service role is to notify patients and responsible parties as directed about changes such as room or roommate changes, mood or behavior changes or a decision to initiate transfer or discharge. During interview on 06/04/12 at 3:42 P.M., Resident #54 stated she received a new roommate on the previous Friday (06/01/12) and had not received notice from the facility prior to the roommate's arrival. During interview with Social Worker (SW) #27 on 06/07/12 at 4:20 P.M., it was stated she would alert a resident if they were receiving a new roommate. During interview on 06/07/12 at 4:57 P.M., with SW # 3 it was stated she used to use room change forms, however they no longer do that because of the electronic documentation that is used. SW #3 also stated there would be an electronic note made by the staff involved in the room change and as of right now there is no policy in place to define who is responsible for notification of room changes involving residents residing in the facility. During interview with the facility Administrator on 06/08/12 at 11:40 A.M., it was verified Resident #54 received a roommate on 06/01/12 and was not notified by staff prior to the roommate's arrival. It was also verified the facility staff are still responsible for completing the room change forms. 2. Review of the medical record for Resident #172 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), a comprehensive assessment, revealed Resident #172 is able to make herself understood and able to understand others. The MDS also revealed Resident #172 scored a 15/15 on the Brief Interview for Mental Status (BIMS). Review of a document titled Notification of Room/ Roommate Change revealed areas for staff to document if the resident was informed of a new roommate and areas for any comments. Review of a form titled Regulation and Role Table, dated June 2012 revealed the social service role is to notify patients and responsible parties as directed about changes such as room or roommate changes, mood or behavior changes or a decision to initiate transfer or discharge. During interview on 06/04/12 at 5:24 P.M., Resident #172 stated she was moved from room [ROOM NUMBER] to room [ROOM NUMBER]. Resident #172 also stated when she had returned from therapy one day the facility staff were moving her to another room. Resident #172 verified she was not told why she was being moved and had not received notice prior to the move. During interview with Social Worker (SW) #27 on 06/07/12 at 4:20 P.M., it was stated she would alert a resident if they were receiving a new roommate. During interview on 06/07/12 at 4:57 P.M., with SW # 3 it was stated she used to use room change forms, however they no longer do that because of the electronic documentation that is used. SW #3 also stated there would be an electronic note made by the staff involved in the room change and as of right now there is no policy in place to define who is responsible for notification of room changes involving residents residing in the facility. During interview with the facility Administrator on 06/08/12 at 11:40 A.M., it was verified Resident #172 was moved to another room on 05/17/12 and was not notified by staff prior to the move. It was also verified the facility staff are still responsible for completing the room change forms.",2017-01-01
7812,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2012-06-08,272,D,0,1,U80L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to comprehensively assess 2 residents, #147 for incontinence frequency and #69 for relevant diagnoses, out of 22 residents whose MDS (Minimum Data Set) were reviewed. Findings include: 1. Resident #147 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the comprehensive admission MDS (Minimum Data Set) dated January 12, 2012, assessed the resident as occasionally incontinent of urine. Review of the Resident Response Rate Report for toileting revealed that the resident had 8 incontinent eipisodes and at least one continent episode between January 6, 2012, and January 12, 2012. Observations of the resident were conducted on June 5, 2012. No odors or signs of wetness or incontinence were observed. Interviews were conducted on June 5, 2012, with Registered Nurse Assessment Coordinator (RNAC) staff #100. Staff stated that she failed to comprehensively assess the resident's incontinence frequency. She stated that the resident had 8 incontinence episodes during the look-back period of the comprehesive MDS assessment dated [DATE], and should have been assessed as frequently incontinent and not occasionally incontinent. Staff stated that she suspects that she did not include the final day of the look-back period in the Resident Response Rate Report when she used it as supporting documentation for the comprehensive assessment. Interviews were conducted on June 8, 2012, with RNAC staff #100 regarding the policy and procedures of the facility for comprehensively assessing the resident. A verbal policy and procedure was communicated which is to follow the RAI (Resident Assessment Instrument) manual. The RAI manual instructs to code as frequently incontinent if during the 7-day look-back period, the resident was incontinent of urine during seven or more episodes but had at least one continent void. 2. Resident #69 was admitted on [DATE], with [DIAGNOSES REDACTED]. A discharge summary from the hospital dated January 11, 2012, included [DIAGNOSES REDACTED]. Review of the most recent comprehensive annual MDS (Minimum Data Set) dated January 24, 2012, assessed the resident to have an indwelling foley catheter and a [DIAGNOSES REDACTED]. Observations of the resident were conducted on June 4, 2012, and the resident was observed to have an indwelling foley catheter to bedside drainage. The resident also stated during the course of an interview on June 4, 2012, that she had [MEDICAL CONDITION] and an indwelling foley catheter. Interviews were conducted on June 6, 2012, with Registered Nurse Assessment Coordinator (RNAC) staff #58 who completed the annual MDS assessment dated [DATE]. Staff stated that she should have coded [MEDICAL CONDITION] bladder on the MDS, but failed to do so. She stated she was aware of the [DIAGNOSES REDACTED]. Staff stated that the [DIAGNOSES REDACTED]. Interviews were conducted on June 8, 2012, with RNAC staff #100 regarding the policy and procedures of the facility for comprehensively assessing the resident. A verbal policy and procedure was communicated which is to follow the RAI (Resident Assessment Instrument) manual. The RAI manual instructs to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status and to check all the active [DIAGNOSES REDACTED].",2017-01-01
7813,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2012-06-08,278,D,0,1,U80L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure the accuracy of 2 of 22 residents whose Minimum Data Sets (MDS) were reviewed (residents #69 and #147). Findings include: 1. Resident #147 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the admission MDS (Minimum Data Set) dated January 12, 2012, assessed the resident as occasionally incontinent of urine. Review of the Resident Response Rate Report for toileting revealed that the resident had 8 incontinent eipisodes and at least one continent episode between January 6, 2012, and January 12, 2012. Observations of the resident were conducted on June 5, 2012. No odors or signs of wetness or incontinence were observed. Interviews were conducted on June 5, 2012, with Registered Nurse Assessment Coordinator (RNAC) staff #100. Staff stated that she failed to accurately assess the resident's incontinence frequency. She stated that the resident had 8 incontinence episodes during the look-back period of the MDS assessment dated [DATE], and should have been assessed as frequently incontinent and not occasionally incontinent. Staff stated that she suspects that she did not include the final day of the look-back period in the Resident Response Rate Report when she used it as supporting documentation for the assessment. Interviews were conducted on June 8, 2012, with RNAC staff #100 regarding the policy and procedures of the facility for accurately assessing the resident. A verbal policy and procedure was communicated which is to follow the RAI (Resident Assessment Instrument) manual. The RAI manual instructs to assess the resident as frequently incontinent if during the 7-day look-back period, the resident was incontinent of urine during seven or more episodes but had at least one contienent void. 2. Resident #69 was admitted on [DATE], with [DIAGNOSES REDACTED]. A discharge summary from the hospital dated January 11, 2012, included [DIAGNOSES REDACTED]. Review of the most recent annual MDS (Minimum Data Set) dated January 24, 2012, assessed the resident to have an indwelling foley catheter and a [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS dated [DATE], also assessed the resident to have an indwelling foley catheter and a [DIAGNOSES REDACTED]. Observations of the resident were conducted on June 4, 2012, and the resident was observed to have an indwelling foley catheter to bedside drainage. The resident also stated during the course of an interview on June 4, 2012, that she had [MEDICAL CONDITION] and an indwelling foley catheter. Interviews were conducted on June 6, 2012, with Registered Nurse Assessment Coordinator (RNAC) staff #58 and #100 who completed the annual MDS assessment dated [DATE] and the quarterly MDS assessment dated [DATE]. Staff stated that they should have coded [MEDICAL CONDITION] bladder on the MDS, but failed to do so. They stated that they were aware of the [DIAGNOSES REDACTED]. Staff stated that the [DIAGNOSES REDACTED]. Interviews were conducted on June 8, 2012, with RNAC staff #100 regarding the policy and procedures of the facility for comprehensively assessing the resident. A verbal policy and procedure was communicated which is to follow the RAI (Resident Assessment Instrument) manual. The RAI manual instructs to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status and to check all the active [DIAGNOSES REDACTED].",2017-01-01
7814,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2012-06-08,279,D,0,1,U80L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to develop a comprehensive care plan for 2 of 22 residents whose care plans were reviewed, (#1 and #75. The finding were: 1. Resident #75 was readmitted to the facility on [DATE] after being hospitalized . His [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 15 on the BIMS (brief interview for mental status), indicating he was independent in his cognitive skills for decision making. He was coded to be at risk for malnutrition and weight loss, even though he was 72 inches tall and weighed 232 lbs. He was coded as receiving a therapeutic diet. He was marked as having no natural teeth. Difficulty in chewing was not marked as a problem. A mechanically altered diet was not indicated. During an interview with resident #75 on 06/04/2012 at 2:18 PM, the resident stated he had denture problems, I have dentures but can't eat with them - they fall out when I try to eat something. Resident #75 also stated he had trouble chewing, I can't eat most of the food because I can't chew it. Record Review: Review of the computerized physician orders [REDACTED]. Review of the care plans revealed there was not a care plan specific to either his difficulty chewing or his dental status with ill fitting dentures. He was care planned for an ADL self-care-deficit related to impaired mobility, lack of motivation to help himself, and obesity as evidenced by the need for total assistance of staff for care. The care plan goal was, Will maintain existing ADL self performance and functional mobility to limit further decline daily thru the next review. The approaches, in pertinent part, were: Assist of one with daily hygiene, grooming, dressing, oral care, and set up for meals. Encourage and offer set up with oral care AM and PM and as needed (prn). Encourage to assist with and exercise during daily care activities such as dressing and grooming Encourage to participate in self care Resident at risk for weight loss related to decreased po (oral) intake per resident's choice. Will experience no more than 7% weight loss through next review Encourage and assist as needed to consume foods and/or supplements and fluids offered Provide diet as ordered Report signs or symptoms of diet and/or texture intolerance During an interview with the interim Administrative Director of Nursing Services (ADNS) on 6/8/12 at 3:50 PM, she stated if there was a problem the expectation would be that nursing would develop (or revise)a care plan. If we identified a problem in our meetings, we would have care planned it and acted on the issue. Resident #75 comes to his care conferences, we ask about problems at that time. I would have expected him to speak up with these issues. 2. Resident # 1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set date 10/11/11 revealed resident #1 had range of motion (ROM) limitations on both sides of his body, and he was not coded as receiving any therapy services or restorative/ROM services. During an interview with a staff nurse responsible for the care and services for resident #1, on 6/4/12 at 4:11 PM, she stated Resident #1 had a left hand contracture but was not receiving any ROM services, nor did he have a splint device in place. Review of the Computerized Physician order [REDACTED]. Review of the Occupational Therapy (OT) note dated 4/29/12 revealed a note stating the resident had recently been screened by OT. The screen concluded, Resident screened from activities of daily living (ADL) decline reports. Spoke to nursing including LPNs and CNA staff. Resident remains able to feed self with tray set up using large handled adaptive utensils and finger foods (mainly sandwiches) Resident has had no changes with ADLs, relying on staff for years with ADLs. Res has a left hand contracture and refusing all orthotics previously attempted. No further skilled OT at this time. Observation of resident #1 on 6/4/12 at 6:08 PM confirmed the presence of the contracture. The resident held his hands in a fist-like position. The surveyor asked him if he could open his hands. The resident was able to open his right hand but was only able to partially straighten his middle 2 fingers. His ring finger, little finger and thumb would not straighten. The surveyor asked him about the towel in his hand. He shook his head and responded, no! The Therapy Director was interviewed on 6/6/12 at 8:45 AM. She acknowledged resident #1 had a left hand contracture. Review of the care plans dated 4/2/12 did not reveal any plan related to the resident's contracture. Nurse #41 was interviewed on 6/7/12 at 9:30 AM. She stated nursing was responsible for developing care plans. We would care plan a contracture. Resident #1's care plan probably got dropped years ago because of his non-compliance and refusals of care. During an interview with the interim Administrative Director of Nursing Services (ADNS)on 6/8/12 at 3:50 PM, she stated if there was a problem the expectation would be that nursing would develop a care plan. If we identified a problem in our meetings, we would have care planned it. She stated a contracture should be care planned but continued that because resident #1 had been a resident since 1979, she guessed he probably had a care plan for a contracture at one time but it had since been discontinued.",2017-01-01
7815,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2012-06-08,280,D,0,1,U80L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to update the comprehensive care plan to reflect the use of a [MEDICAL CONDITION] medication for 1 of 22 residents whose care plans were reviewed, (#19). Findings include: Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was re-admitted on [DATE] after being hospitalized . During review of the clinical record on 6/4/12, the resident was identified as receiving two antipsychotic medications: [REDACTED]. Review of 3 Minimum Data Sets ((MDS) dated [DATE], 1/10/12, nd 10/18/11 reflected use of the antipsychotic meds. However, when assessing the resident's behavior, no hallucinations (perceptual experiences in the absence of real external sensory stimuli) or delusions (misconceptions or beliefs that are firmly held, contrary to reality) were noted to be present. Each of the three quarterly MDSs consistently noted that behaviors were not exhibited. (Behaviors such as physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) or Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) or other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Additionally, the resident was not assessed to have rejected evaluation or care, he had not wandered, and there was no change identified in recent behaviors. Upon readmission to the facility in 7/2011 the MDS did not identify the use of antipsychotic meds. Similarly, none of the behaviors identified above were noted to be present. The antipsychotic medications were started in 8/2011, approximately a month after admission to the facility. Review of the 6/1/12 Computerized Physicians Orders revealed the resident was ordered to receive [MEDICATION NAME] 25 mg. every day for dementia with psychotic features. The order had initially been written on 8/23/2011. Additionally, [MEDICATION NAME] 50 mg. was to be administered at bedtime each evening for dementia with psychotic features. That order had been written 8/29/11. [MEDICATION NAME] 0.5 mg. had been initially ordered on [DATE] to be administered every morning for dementia as evidenced by verbal and physical aggression. Review of the care plans did not reveal a plan specifically related to use of the antipsychotic medications. Instead, only the behaviors were addressed (verbal/ physical aggression - cursing,yelling, and hitting staff members, throws walker which results in fall, related to dementia/sundowning). No non-pharmacologic interventions related to managing the behaviors were identified or addressed. The care plan goal was that the resident would not harm himself or others through the next 90 days. The approaches were: administer medications per physician orders [REDACTED]. Observe for side effects and notify physician as needed. Approach slowly and slightly to the side. Attempt to use consistent routines and caregivers for ADLs. Identify stressful times of day and schedule activities at other times. Another Care Plan problem identified that the resident was an elopement risk as evidenced by statements that he wants to go home. He was noted to shake the door handles related to a cognitive impairment related to dementia. The goal of the exit seeking care plan was to not allow the resident to leave the center unattended. Approaches to achieve that goal included, administer medication per orders and observe for effectiveness and for side effects such as but not limited to dry mouth, dizziness, drowsiness. Report to physician as needed. Allow to vent feelings and/or frustration. Attempt consistent routines and caregivers. Avoid leaving unattended or unobserved for long periods of time. Calmly redirect to an appropriate area. Encourage resident to attend meals and scheduled activities. Observe with visual check frequently. Redirect as needed when exit seeking. Visually observe resident frequently. Nurse #41 was interviewed on 6/8/12 at 10:30 AM. She stated, We do care plans on admission and try to address all areas at that time. She stated the use of the antipsychotic meds for resident #19 was care planned and pointed out the care plan for verbal aggression and stated, that's how we do (care plan) it. During an interview with the interim Administrative Director of Nursing Services (ADNS) on 6/8/12 at 3:50 PM, she stated if there was a problem, the expectation would be that nursing would develop a care plan. If we identified a problem in our meetings, we would have care planned it and acted on the issue. She continued that she would expect the use of the antipsychotic medications to be care planned.",2017-01-01
7816,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2012-06-08,282,D,0,1,U80L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews the facility failed to implement care planned interventions related to falls and personal hygiene for 1 of 22 residents whose care plans were reviewed, (#71). Findings Include: Review of the medical record for Resident #71 revealed the resident was originally admitted to the facility on [DATE]. The resident was hospitalized related to a cardio vascular accident ([MEDICAL CONDITION]) and readmitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), a comprehensive assessment dated [DATE], revealed the resident scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS), is able to make herself understood and is able to understand others. The resident was also assessed to require extensive assist of two staff members for bed mobility, transfers, dressing and toilet use. Resident #71 was assessed to require extensive assist of one staff member for personal hygiene. The MDS also revealed the resident has functional limitations to one side of the upper and lower extremities. Review of the care plans for Resident #71 revealed a plan of care dated 05/11/12 related to the resident's risk for falls due to unsteady gait, pain and a history of falls. Interventions included 2 person assist for transfers, explain procedure and go slowly, bed buddies on left side of bed to assist resident to be aware of bed parameters, bed in low position, encourage and assist as needed to wear non slip footwear, encourage to transfer and change position slowly, fall mats and staff education on 2 person assist with turning and transfers with sling lift. A plan of care also dated 05/11/12 was reviewed related to Resident #71's self care deficit which included interventions of a 2 person assist with all transfers. A plan of care related to Resident #71's self care deficit related to the recent cardiovascular accident ([MEDICAL CONDITION]) with left sided [MEDICAL CONDITION] had been developed. The interventions for the plan of care include to assist with daily hygiene, grooming, dressing, oral care and eating as needed. Further review of the medical record revealed nurses notes dated 06/03/12 at 8:35 A.M., which stated a Certified Nurse Aide (CNA) was providing incontinence care to Resident #71 when the resident fell out of bed and landed on the floor. According to the nurses notes Resident #71 did not lose consciousness, however, did complain of right leg pain and had a laceration to her left temple area near the left ear. First aid was provided by the facility staff and an ambulance service was notified to transport Resident #71 to the emergency room for evaluation of the injuries sustained from the fall. The nurses notes revealed Resident #71 returned from the emergency roiagnom on [DATE] with the [DIAGNOSES REDACTED]. Resident #71 was observed in bed on 06/04/12 at 10:42 A.M., and 6/5/12 at 12:19 P.M., with bolsters to both side of the bed. On 6/6/12 at 8:46 A.M., Resident #71 was observed in bed with the foot of the electronic bed elevated with the resident's knees bent, the head of the bed was slightly elevated as was the height of the bed elevated. At the time of the observation CNA #112 came to the room to retrieve the breakfast tray and did not acknowledge the height of the Resident's bed. At 8:54 A.M., on 06/06/12 Licensed Practical Nurse #70 was notified by the surveyor of the height of the bed. LPN #70 verified the height of the bed was too high and was not in accordance with the current plan of care related to Resident #71's history of falls from the bed. Resident #71 was observed in bed on 06/06/12 at 9:06 A.M. Two staff members, Licensed Practical Nurse (LPN) # 70 and Certified Nurse Aide (CNA) #112, were observed providing care for the resident. Resident #71 was dressed and transferred to the wheel chair using a hoyer lift. At 9:24 A.M., resident #71 was noted to be seated in the wheel chair with her hair uncombed and face that appeared to be unwashed with eye drainage noted and food to the left side of her face. At 9:36 A.M., Resident #71 had requested to go back to bed due to an increase in discomfort. After the staff transferred the resident back to bed Resident #71 verified the staff had not combed her hair or washed her face when they assisted her with ADLs prior to getting up to the wheel chair. During interview with Resident #71's daughter on 06/06/12 it was stated she often finds her mother's face unwashed and hair uncombed during her daily visits. Resident #71 was observed on 6/7/12 at 10:36 A.M., to be in bed with a hospital gown on and her hair was uncombed. Resident #71 verified she had not received AM care yet at the time of the observation. During interview with the CNA assigned to care for Resident #71 on 06/07/12 at 11:30 A.M., it was verified she had not provided AM care for the resident. The CNA stated she thought the Occupational Therapist (OT) had worked with the resident that morning. During interview with OT # 31 on 06/07/12 at 11:35 A.M., it was verified that she had not assisted Resident #71 with her AM care needs. During interview with the Director of Nursing (DON) on 06/07/12 it was verified Resident #71 should receive assistance with activities of daily living as listed on the care plan which would include combing her hair and washing her face.",2017-01-01
7817,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2012-06-08,309,D,0,1,U80L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to ensure necessary care and services for 2 out of 32 sampled residents in Stage 2. One resident (#74) was reviewed for skin conditions and one resident was reviewed for [MEDICAL TREATMENT] (#124). 1. Observation of resident #74 on 06/04/2012 at 5:40 PM revealed 3 small scabs on her left forearm and a small bruise on her right forearm. Review of a significant change Minimum Data Set ((MDS) dated [DATE] revealed resident #74 was coded as independent in her cognitive skills for daily decision making. She required extensive assistance with activities of daily living (ADLs). She was totally dependent on staff for bathing and range of motion (ROM) due to an impairment on 1 side of her body, no skin conditions were noted. The resident is receiving Hospice services. Review of the care plan revealed resident #74 had been identified to be at risk for injury related to falls due to impaired balance and an unsteady gait due to late effects [MEDICAL CONDITION] arthritis. The resident was therefore identified to need ADL assistance. The facility interventions included Minimize falls and risk for injury related to falls Administer medications as ordered Encourage and assist as needed to wear proper and non slip footwear Encourage to use walker and assistance of staff when ambulating Have commonly used articles within easy reach Toilet before meals, before bed, during night, and as needed Additionally, the care plan identified an ADL self care deficit for resident #74. Interventions included, maintain existing ADL self performance by assisting with daily hygiene, grooming, dressing, oral care and eating as needed (dependent feeder). Review of Interdisciplinary notes did not reveal any documentation identifying or addressing the resident's skin condition: A General Progress Note written in the resident's medical record stated, Resident in review for a quarterly MDS assessment and care plan review. She continues to receive hospice services. She only takes one medication and that is her [MEDICATION NAME]. She is alert and able to make her wants and needs known. Sometimes you have to ask her to repeat herself. She requires assistance of staff to meet her needs. She is incontinent of bowel and bladder. She receives treatment to excoriation of her buttocks and preventive skin care as ordered. She does not have any pressure wounds at this time. When interviewed about her pain she denied any pain at this time or any in the last five days. She is not experiencing any acute problems at this time. She will continue to be observed for any problems. A Nutrition/Weight Note (quarterly) written in the resident's medical record on 4/10/2012 at 13:59 stated, Resident continues with hospice services for end of life care. Weights and labs have been discontinued since 1/12. Most recent weight was 87.6 pounds on 1/1/12. Continues with pureed diet with honey-thick liquids; consumed 25-50% of most meals x 7 days with occasional refusals. Resident is also refusing medications at this time. Skin is intact, however, excoriation noted to buttocks. She is at risk for skin breakdown due to lack of mobility and refusal to be repositioned. Will continue to monitor for changes via facility staff. A Social Services Note was written in the resident's medical record on 4/10/2012 at 13:53 and stated, Resident continues hospice services. She is deemed to have capacity to make medical decisions. She has MPOA in place. Code status is DNR (do not resuscitate). Resident is alert. She has communication deficits due to slurred speech and she is very hard of hearing. Mental status interview conducted with a BIMS score 9/15. She reported minimal mood problems but acknowledged feeling tired and having no energy. Resident had one episode during this review in which she refused all ADL care from hospice staff, pushed staff away and yelled at them. She is not currently prescribed any psychoactive medication for mood or behavior. She is up in wheelchair most days and participates in activities of choice. Discharge plan continues for LTC. Resident indicated it is not necessary to ask her about returning to the community. She was informed of her care conference scheduled for 4/18/12. A Change of Condition Note was written in the resident's medical record on 3/28/2012 at 16:38 and stated, Res noted to fall in floor at 4:15pm. Res was sitting in w/c around nurses station; she was attempting to pick something up off of the floor and fell head first out of wheelchair (w/c). Assisted back into w/c; small hematoma found to be noted to left forehead. Denies any pain at this time. Neuro checks initiated at time of fall and remain WNL's at this time. Reminded res to ask for assistance with things on the floor or when things are out of reach. MPOA notified at 4:40 pm via phone conversation. The on call physician for Family Practice was notified of the fall and instructed this nurse to continue neuro checks and if a change in neuro status arose call back for further orders. At this time, res sitting comfortable in w/c at nurses station. Will continue to observe res status. Interviews: On the morning of 6/8/12 several staff members responsible for the care and services for resident #74 were asked about the bruising and scabs on resident #74's arms. Certified Nursing Aide (CNA) #28, stated that she was not aware of the resident's skin condition. Nurse #41 also stated no awareness of the resident's skin condition. CNA #40 stated that she had noticed the scabs yesterday. She stated that she had reported to nursing her observations, but stated at 8:15 on 6/8/12, we are supposed to notify the nurse and post in the alert charting. LPN #10 also stated that she was not aware of the resident's skin condition but stated she had been working nights on a different hall and hadn't worked on this hall for 2 months. Also on the morning of 6/8/12 a CNA, who asked not to be identified, informed the surveyor that he/she had noticed marks on the resident's forearm, last week, Wednesday. The CNA stated that the skin condition had been relayed on to a nurse however the nurse had not assessed the resident at that time. The CNA voiced a concern regarding the lack of an assessment on Wednesday, so had reported the skin condition to a different nurse on Thursday. The CNA stated that the second nurse did not assess the resident. The CNA stated she told both nurses the condition looked like fingernail marks. The CNA stated when she reported the condition to the second nurse on Thursday, another CNA had witnessed the conversation. The Administrative Director of Nursing Services (ADNS) was advised of the above on 6/8/12 at approximately 10:00 AM. She was not aware of the scabs/bruise on the resident's arm. She accompanied the surveyor to observe the resident. The ADNS acknowledged the skin conditions. She immediately began an investigation of the skin condition. At 3:50 PM on 6/7/12 the ADNS stated that her expectation would be for the CNAs to report the skin condition to the nurses and the nurses to follow the facility policy, assessing the resident and ensuring the appropriate care and services. The ADNS acknowledged the nurses did not follow the facility policy and should have assessed the resident when the condition was reported. 2. Review of the medical record for Resident #124 revealed an original admission date of [DATE] and a most recent readmission of 05/29/12 with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), a comprehensive assessment dated [DATE], revealed Resident #24 was able to make herself understood and was able to understand others. According to the MDS Resident #124 scored a 15/15 on the Brief Interview for Mental Status (BIMS) which would indicate no cognitive impairment. Review of the care plans for Resident #124 revealed a plan of care dated 03/14/12 related to the resident's [DIAGNOSES REDACTED]. According to the plan of care the facility planned to provide Resident #124 with a meal to take to the [MEDICAL TREATMENT] center. During interview with Resident #124 on 06/07/12 at 9:18 A.M., it was stated she attends [MEDICAL TREATMENT] three days a week on Tuesday, Thursday and Saturday. Resident #124 stated she leaves the facility around 10:15 A.M., and the facility provides her with a sack lunch to take with her. Resident #124 also stated she would like to have a lunch meat sandwich or a chicken salad sandwich and the facility has been sending peanut butter and jelly. Resident #124 stated she does not like peanut butter. Resident #124 also stated during the interview that her son sometimes has to bring her food to the [MEDICAL TREATMENT] center and she has never been asked by the facility staff about her food likes and dislikes. During interview with the facility's Dietitian on 06/07/12 at 10:06 A.M., it was verified Resident #124 should have a sack lunch that contains double portions of protein. At the time of the interview it was confirmed that Resident #124 had received a sack lunch that contained a peanut butter sandwich on 6/5/12. During interview with dietary aide #125 on 06/07/12 at 10:20 A.M., it was verified she had made a mistake and packed a peanut butter sandwich for the resident's sack lunch. Dietary aide #125 stated during the interview that she knows who is to get a sack lunch by looking at the snack list. Dietary aide #125 stated she packed Resident #124's sack lunch for 6/7/12 with a tuna sandwich. When asked how much tuna she used to make the sandwich the dietary aide stated she just put pieces on the bread. The facility's dietitian verified at the time of the interview that dietary aide #125 should have measured out 4 ounces of tuna to make the sandwich correctly. Dietary aide #125 verified at 10:20 A.M., she had never been trained on how to make sack lunches or measure food portions. At 10:24 A.M., dietary aide #125 stated Resident #124's sack lunch consisted of an unmeasured amount of tuna between two pieces of bread and an 8 ounce can of ginger ale. The facility's dietitian verified the sack lunch sent with Resident #124 on 06/07/12 was not reflective of her physician ordered diet and was not a complete meal.",2017-01-01
7818,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2012-06-08,312,D,0,1,U80L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review observation and interviews the facility failed to provide assistance with grooming for 1 of 3 residents reviewed for activities of daily living, (71). Findings Include: Review of the medical record for Resident #71 revealed the resident was originally admitted to the facility on [DATE]. The resident was hospitalized related to a cardio vascular accident ([MEDICAL CONDITION]) and readmitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), a comprehensive assessment dated [DATE], revealed the resident scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS), is able to make herself understood and is able to understand others. The resident was also assessed to require extensive assist of two staff members for bed mobility, transfers, dressing and toilet use. Resident #71 was assessed to require extensive assist of one staff member for personal hygiene. The MDS also revealed the resident has functional limitations to one side of the upper and lower extremities. Review of the care plans for Resident #71 revealed a plan of care related to the resident's self care deficit due to the recent cardiovascular accident ([MEDICAL CONDITION]) with left sided [MEDICAL CONDITION]. The interventions for the plan of care included to assist with daily hygiene, grooming, dressing, oral care and eating as needed. Review of the facility's policy for AM Care, dated 12/2009, revealed staff should wash, rinse and dry the resident's face, hands, back, perineal and anal area. The policy also stated staff should apply deodorant and make-up, comb hair and shave as needed. Resident #71 was observed in bed on 06/06/12 at 9:06 A.M. There were two staff members, Licensed Practical Nurse (LPN) # 70 and Certified Nurse Aide (CNA) #112 providing care to the resident. Resident #71 was dressed and transferred to the wheel chair using a hoyer lift. At 9:24 A.M., Resident #71 was noted to be seated in the wheel chair with her hair uncombed and face that appeared to be unwashed with eye drainage noted and food to the left side of her face. At 9:36 A.M., Resident #71 had requested to go back to bed due to an increase in discomfort. After the staff transferred the resident back to bed Resident #71 verified that staff had not combed her hair or washed her face when they assisted her with ADLs prior to assisting her to get into the wheel chair. During interview with Resident #71's daughter on 06/06/12 it was stated that she often finds her mother's face unwashed and hair uncombed during her almost daily visits to the facility. Resident #71 was observed on 6/7/12 at 10:36 A.M., to be in bed with a hospital gown on and her hair was uncombed. Resident #71 verified she had not received AM care at the time of the earlier observation. During interview on 6/7/12 at11:30 AM with the CNA assigned to care for Resident #71, it was verified she had not provided AM care for the resident. The CNA stated she thought the Occupational Therapist (OT) had worked with the resident that morning. During interview with OT # 31 on 06/07/12 at 11:35 A.M., it was verified she had not assisted Resident #71 with her AM care needs. During interview with the Director of Nursing (DON) on 06/07/12 it was verified Resident #71 should receive assistance with AM care which would include combing her hair and washing her face.",2017-01-01
7819,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2012-06-08,323,G,0,1,U80L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews the facility failed to prevent a fall for a resident who is dependent on staff for bed mobility from a fall. The fall resulted in injury to the resident. This involved one of six residents (#71) identified by the facility as having a fall in the last 30 days. Findings include: Review of the medical record for Resident #71 revealed the resident was originally admitted to the facility on [DATE]. The resident was hospitalized related to a cardio vascular accident (CVA) and readmitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), a comprehensive assessment dated [DATE], revealed the resident scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS), is able to make herself understood and is able to understand others. The resident was also assessed to require extensive assist of two staff members for bed mobility, transfers, dressing and toilet use. Resident #71 was assessed to require extensive assist of one staff member for personal hygiene. The MDS also revealed the resident has functional limitations to one side of the upper and lower extremities. Review of the care plan for Resident #71 revealed a plan of care dated 05/11/12 related to the resident's risk for falls due to an unsteady gait, pain and a history of falls. Interventions included 2 person assist for transfers, explain procedure and go slowly, bed buddies on the left side of the bed to assist the resident in awareness of bed parameters, bed to be positionined in the low position, encourage and assist as needed to wear non slip footwear, encourage to transfer and change position slowly, fall mats and staff education on 2 person assist with turning, and transfers with sling lift. A plan of care also dated 05/11/12 was reviewed related to Resident #71's self care deficit which included interventions of a 2 person assist with all transfers. Further review of the medical record revealed nurses notes dated 06/03/12 at 8:35 A.M., which stated a Certified Nurse Aide (CNA) was providing incontinence care to Resident #71 hen the resident fell out of bed and landed on the floor. According to the nurses notes, Resident #71 did not lose consciousness, however, did complain of right leg pain and did have a laceration to her left temple area near the left ear. First aide was provided by the facility staff and an ambulance service was notified to transport Resident #71 to the emergency room for evaluation of the injuries sustained from the fall. The nurses notes revealed Resident #71 returned from the emergency roiagnom on [DATE] with the [DIAGNOSES REDACTED]. Review of a document titled Patient Information Worksheet (PIW), and identified by the facility as as a document staff can use as a guide to the care required by residents residing in the facility, revealed Resident #71 requires two staff members for all transfers. The resident information found in the kiosk, an electronic health information device, stated Resident #71 required the assistance of two staff members for activities of daily living (ADLs). Resident #71 was observed in bed on 06/04/12 at 10:42 A.M., and 6/5/12 at 12:19 P.M., with bolsters to both side of the bed. On 6/6/12 at 8:46 A.M., Resident #71 was observed in bed with the foot of the electronic bed elevated with the Resident's knees bent, the head of the bed was slightly elevated as was the height of the bed elevated. At the time of the observation CNA #112 came to the room to retrieve the breakfast tray and did not acknowledge the height of the Resident's bed. At 8:54 A.M. on 06/06/12 Licensed Practical Nurse #70 was notified by the surveyor of the height of the bed. LPN #70 verified during interview the height of the bed was too high and was not in accordance with the current plan of care related to Resident #71's history of falls from the bed. During interview with the facility Administrator on 06/06/12 at 12:31 P.M., it was verified a CNA, who is currently on suspension from work due to the fall, was alone providing incontinence care to Resident #71 while she was in bed. The investigation into the fall was reviewed with the Administrator at the time of the interview. According to the investigation and the CNA's statement taken by the Administrator, the CNA had been standing on the left side of Resident #71 and had pushed the Resident onto her right side rolling her off the right side of the bed. The statement went on to say the CNA had left the room and alerted LPN #70 of what had occurred. During interview with LPN #70 on 06/06/12 at 12:57 P.M., with the Administrator present, it was verified the CNA who had rolled Resident #71 out of bed had been the one to alert her of the incident. According to LPN #70, when she entered the room Resident #71 was lying on her back on the floor between the bed and wall and had stated the aide was being mean to her when providing care. LPN #70 verified the injury to the left side of the Resident's head and could not be sure what Resident #71's head had come in contact with to cause the laceration. LPN #70 stated during the interview that she had notified the physician and received an order to send Resident #71 to the emergency room for evaluation of her injuries. During interview with LPN # 54 on 06/07/12 at 8:34 A.M., it was verified Resident #71 requires two staff members when providing care. During interview with CNAs #16, #112 and #109 on 06/07/12 at 9:07 A.M., it was stated there must be 2 staff members to provide care for Resident #71. The CNAs also stated they get information on how to care for residents residing in the facility from the PIW and the kiosk that are hanging on the walls in the hallway.",2017-01-01
7820,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2012-06-08,329,D,0,1,U80L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure the presence of an appropriate [DIAGNOSES REDACTED]. The facility failed to attempt a Gradual Dose Reduction (GDR) in the absence of any exhibited behaviors for which the medication had been prescribed, for 1 (#19) of 2 residents reviewed out of 3 residents identified as using antipsychotic medications. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was re-admitted on [DATE] after being hospitalized . This was an open Adult Protection Services (APS) case. During review of the clinical record on 6/4/12, the resident was identified as receiving two antipsychotic medications: [REDACTED]. Review of 3 Minimum Data Sets ((MDS) dated [DATE], 1/10/12, nd 10/18/11 reflected use of the antipsychotic meds. However, when assessing the resident's behavior, no hallucinations (perceptual experiences in the absence of real external sensory stimuli) or delusions (misconceptions or beliefs that are firmly held, contrary to reality) were noted to be present. Each of the three quarterly MDSs consistently noted that behaviors were not exhibited. (Behaviors such as physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) or Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) or other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Additionally, the resident was not assessed to have rejected evaluation or care, he had not wandered, and there was no change identified in recent behaviors. Upon readmission to the facility in 7/2011 the MDS did not identify the use of antipsychotic meds. Similarly, none of the behaviors identified above were noted to be present. The antipsychotic medications were started in 8/2011, approximately a month after admission to the facility. Observations: Observation of the resident during the six days of survey, 6/3/12 - 6/8/12 did not reveal resident #19 to be out of bed. He did yell out for help occasionally, but was not observed to display any verbal or physical aggression. Record Review: Review of the 6/1/12 Computerized Physicians Orders revealed the resident was ordered to receive [MEDICATION NAME] 25 mg. every day for dementia with psychotic features. The order had initially been written on 8/23/2011. Additionally, [MEDICATION NAME] 50 mg. was to be administered at bedtime each evening for dementia with psychotic features. That order had been written 8/29/11. [MEDICATION NAME] 0.5 mg. had been initially ordered on [DATE] to be administered every morning for dementia as evidenced by verbal and physical aggression. Review of the care plans did not reveal a plan specifically related to use of the antipsychotic medications. Instead, only the behaviors were addressed (verbal/ physical aggression - cursing, yelling, and hitting staff members, throws walker which results in fall, related to dementia/sundowning). No non-pharmacologic interventions related to managing the behaviors were identified or addressed. The care plan goal was that the resident would not harm himself or others through the next 90 days. The approaches were: administer medications per physician orders [REDACTED]. Observe for side effects and notify physician as needed. Approach slowly and slightly to the side. Attempt to use consistent routines and caregivers for ADLs. Identify stressful times of day and schedule activities at other times. Another Care Plan problem identified that the resident was an elopement risk as evidenced by statements that he wants to go home. He was noted to shake the door handles related to a cognitive impairment related to dementia. The goal of the exit seeking care plan was to not allow the resident to leave the center unattended. Approaches to achieve that goal included, administer medication per orders and observe for effectiveness and for side effects such as but not limited to dry mouth, dizziness, drowsiness. Report to physician as needed. Allow to vent feelings and/or frustration. Attempt consistent routines and caregivers. Avoid leaving unattended or unobserved for long periods of time. Calmly redirect to an appropriate area. Encourage resident to attend meals and scheduled activities. Observe with visual check frequently. Redirect as needed when exit seeking. Visually observe resident frequently. Review of a 10/18/11 assessment revealed documentation which stated, in pertinent part, that the resident was a [AGE] year old male with a [DIAGNOSES REDACTED]. The residdent was scheduled to receive [MEDICATION NAME] twice a day and no adverse effects had been noted. The assessment continued that the resident continues with behaviors at times. The resident can be redirected or staff leave and reapproach at a later time. Staff will continue to observe for behaviors and make adjustments as necessary through next review. A 1/5/12 assessment noted, [AGE] year old male resident with [DIAGNOSES REDACTED]. Resident's behaviors controlled well on current medications. Resident has occasional verbal aggression at staff. Resident alert and oriented to name only. Will continue to observe for new onset or increasing frequency of behaviors through next review. The 3/23/12 assessment noted [AGE] year old male resident with [DIAGNOSES REDACTED]. Resident's behaviors controlled well on current medications. Resident has occasional verbal aggression at staff. Resident alert and oriented to name only. Will continue to observe for new onset or increased behaviors. Review of interdisciplinary (IDT) notes, in pertinent part revealed a 5/21/2012 Nurses Notes (NN) stating, Res. continues on [MEDICATION NAME] and [MEDICATION NAME] as ordered for behaviors. Res has had no combative behavior reported over the last week or so. Monitored for meds effectiveness as well as for signs and symptoms of side effects. A 5/7/2012 nursing note stated, Continues on [MEDICATION NAME] and [MEDICATION NAME] as ordered for behaviors. Res has history of verbal and physical aggression. Resident's behaviors well controlled on current dose. Is monitored daily for med's effectiveness as well as for signs and symptoms of side effects. A 4/23/2012 nurse's note stated, Continues on [MEDICATION NAME] and [MEDICATION NAME] as ordered. Res takes these for behaviors and behaviors are well controlled most of time, but occasionally Res will curse and be combative with staff. A 4/3/2012 Social Service Note/Quarterly MDS Assessment and Progress Note stated, Resident lacks capacity to make medical decisions due to dementia. BIMS score 5/15, indicates severe cognitive impairment. He has dementia with behavior disturbance and is prescribed [MEDICATION NAME] and [MEDICATION NAME]. Behaviors have been stable with current medication. A 3/15/2012 nurse's note related to a change of condition stated, Continues on [MEDICATION NAME] UTI; resident usually yells out for any assistance. A 3/14/2012 nurse's note documented a change of condition and stated, Change of Condition Some confusion today. Up in wheelchair Has been up 3 times in wheelchair today and back to bed. Has been to bathroom [ROOM NUMBER] or 7 times today and had 2 bowel movements. Res. cursing at staff at times. Continues on antibiotic therapy. A 2/20/2012 nurse's notes stated, Res up in wheelchair this morning Accepts medications whole without difficulty. Continues on [MEDICATION NAME] and [MEDICATION NAME] for verbal and physical behaviors. Behaviors usually maintained, but at times resident does curse and attempt to strike staff members. A 2/13/2012 nurse's note stated, Can make some needs known. Becomes very agitated and even physically aggressive at times. Curses at staff members at times. A 2/6/2012 Skilled Nursing Note stated, Does not have capacity. Hard of hearing most of time Does strike out and hollar out at staff. Taking [MEDICATION NAME] and [MEDICATION NAME] for behaviors; behaviors maintained well with current med regimen. Review of the Medication Administration Records (MAR) for April, May and June of 2012 revealed resident #19 received [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg every morning for dementia as evidenced by verbal and physical aggression. The order had been originally written on 8/29/11. The MAR indicated [REDACTED]. The behavior monitoring sheets on the MAR for the months of April, May and June 2012 were all blank. Interviews: The Nursing Home Administrator was asked on 6/6/12 at 12:30 about a facility review of the [MEDICAL CONDITION] medications to ensure the appropriate accompanying [DIAGNOSES REDACTED]. He further stated the physician and the pharmacist determined the [DIAGNOSES REDACTED]. Nurse #41 was interviewed at 10:00 AM on 6/7/12. She stated, If they have any behaviors we would chart on these forms. She showed the June 2012 behavior tracking forms for both [MEDICATION NAME] and [MEDICATION NAME]. The forms were blank. She stated if they had any behaviors they would document on the form and in nurses notes and then notify the MD. Nurse #41 was interviewed again on 6/8/12 at 10:30 AM. She stated they consider all residents appropriate for a gradula dose reduction (GDR), After a period of time goes by we try to reduce all psych meds with pharmacy. The Pharmacy Consultant was interviewed on 6/8/12 at approximately 10:37 AM. He stated he had a computer program that would track and identify residents who were appropriate for a GDR. When the program pops a resident for a dose reduction, he reviews the resident's regimen and generates a recommendation to the physician, if appropriate. He continued, I ensure they (the physicians) present a clinical contraindication. The pharmacist was also asked about the appropriateness of the [DIAGNOSES REDACTED]. He agreed that the [DIAGNOSES REDACTED]. He stated he had requested a GDR for resident #19, but the physician declined on 2/17/12, writing, The meds are keeping (the resident) stable. The consultant pharmacist stated resident #19 was due for a GDR 7/11/12. I will address the inappropriate [DIAGNOSES REDACTED]. The problem is the MDs want to use the ICD-9 codes because that is how they bill. The Pharmacist also shared another recommendation to the physician dated 1/13/12 reading Please consider consolidating and discontinuing one of these antipsychotics with the eventual goal of discontinuation. The Pharmacist stated that with regard to monitoring, They use the Eagle Room, a QA tracking tool. Basically they pull any resident with any issues. The identified behaviors are passed on to me and then I evaluate as to effectiveness and appropriateness of the med. The surveyor shared the lack of behaviors on the behavior monitoring sheets and MDS and the few behaviors documented in nursing notes and asked the Pharmacist if resident #19 would be appropriate for a GDR attempt. The Pharmacist agreed resident #19 would be appropriate for an attempt at a GDR, If you don't have the behaviors to justify the use, then a GDR should be attempted.",2017-01-01
7821,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2012-06-08,412,D,0,1,U80L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to provide dental services for 1 (#75) of 3 residents reviewed for dental services out of six resident interviewed who acknowledged having oral health concerns. Findings include: Resident #71 was readmitted to the facility on [DATE] after being hospitalized . His [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 15 on the BIMS (brief interview for mental status), indicating he was independent in his cognitive skills for decision making. No behaviors had been identified on the MDS. He was coded as requiring extensive assistance for activities of daily living (ADLs), and was totally dependent on staff for transfers. He was coded as having range of motion (ROM) impairment on both sides of the lower extremities, to be at risk for malnutrition and weight loss, even though he was 72 inches tall and weighed 232 pounds. He was coded as receiving a therapeutic diet; a mechanically altered diet was not indicated. He was marked as having no natural teeth. Difficulty in chewing was not marked as a problem. He was also coded as having two pressure ulcers, which had been present on admission. During an interview with resident #75 on 06/04/2012 at 2:18 PM, the resident stated he had denture problems, I have dentures but can't eat with them - they fall out when I try to eat something. Resident #75 also stated he had trouble chewing, I can't eat most of the food because I can't chew it. Record Review: Review of the computerized physician orders [REDACTED]. Review of previous CPOs revealed orders for May 2012 and April 2012 also ordering him to receive a regular textured diet. The dietary recommendations were reviewed and revealed the following diet changes: 4/4/12 no added sweets; 3/16/12 increase ProMod (protein supplement); 3/7/12 no added sweets. Review of the care plans revealed there was not a care plan specific to either his difficulty chewing or his dental status with ill fitting dentures. He was care planned for an ADL self care deficit related to impaired mobility, lack of motivation to help himself, and obesity as evidenced by need for total assistance of staff for care. The care plan goal was to maintain existing ADL self performance and functional mobilityand to limit further decline. The approaches, in pertinent part, were: Assist of one with daily hygiene, grooming, dressing, oral care, and set up for meals Encourage and offer set up with oral care AM and PM and prn. Encourage to assist with and exercise during daily care activities such as dressing and grooming Encourage to participate in self care Resident at risk for weight loss related to decreased oral intake per resident's choice. Will experience no more than 7% weight loss through next review Encourage and assist as needed to consume foods and/or supplements and fluids offered Provide diet as ordered Report signs or symptoms of diet and/or texture intolerance Review of the Dietary Note dated 6/4/12 revealed the Dietitian addressed everything but his chewing problems or his ill-fitting dentures. The note stated, Res continues with regular, CCHO, NAS diet. Avg PO intake was 40% x last 7d. At 30d look back res appetite is usually better. Res was recently dx with [DIAGNOSES REDACTED]. and UTI, which may be affecting appetite. [MEDICATION NAME], acidophilus and [MEDICATION NAME] in place. No new labs available in res chart for RD review; however, res has had [MEDICATION NAME] and glycohemoglobin ordered for 6/1. Res [MEDICATION NAME] was recently changed. Decub noted to buttock and per skin note (6/4) res continues to be at risk d/t noncompliance / interventions to prevent skin breakdown. Per 6/1 skin note pressure wound to right buttock measured 6.5x4cm and left buttock measured 5x4.5cm. Tx in place, which includes juven 1 pkt PO BID and vit C. Other pertinent meds/supplements: [MEDICATION NAME], Miramax, vit D. During an observation of the lunch meal on 6/6/12 resident #75 was served squash casserole, a hamburger patty, noodles, salad and pears. The resident stated, I love these noodles! He did not touch the hamburger patty saying he couldn't chew it. He stated he tried the squash casserole,Yes, I tried it and didn't like it. I've had my fill of pears lately. I can't eat the salad because I can't chew it. Observation of lunch on 6/7/12 revealed resident #75 consumed packaged noodles he had in his room, saying he liked noodles and they were easy to eat. Interviews: On 6/7/12 at 11:30 am CNA #89 stated she was not aware of any chewing problems, but had heard him say he wanted a ground diet. Nurse #41 was interviewed on 6/7 at 9:50 am. She stated, We assess the residents every month and ask them if they are having problems (like chewing) at that time. If we are aware of problems, we ask Social Services for their payor source. She stated she was aware resident #75 had no teeth but was not aware he was having any chewing problems. She continued, We honor whatever diet he wants and he has changed his diet often from reg to ground back to reg. We notify the physician of the resident's wishes and then notify dietary after we get the order to change his diet. After the surveyor had asked several staff members about their awareness of resident #75's chewing problems, there was a telephone order written for a ground meat diet dated 6/7/12. Nurse #41 acknowledged at 3:00 PM on 6/7/12 that after her conversation with the surveyor, she asked the resident if he was having chewing problems and what diet he wanted. She stated he told her he wanted ground meat. The nurse did not state that she had addressed his denture status during her conversation with the resident. On 6/8/12 at 9:10 am Resident #71 was asked if he would wear his dentures if they fit. He replied, Yes, I would like to have them realigned, it would help me talk better and eat better. On 6/8/12 at approximately 11:00 AM the Nursing Home Administrator (NHA) stated he had asked resident #75 if he wanted dentures because he was having trouble chewing. The NHA and surveyor walked to the resident's room. The NHA asked resident #71 if he remembered talking with him about getting dentures. Resident #71 responded he did not recall the conversation and then stated, I have dentures but they need realigned. The NHA informed the resident they would get him to the dentist. In response to surveyor inquiries related to the residen'ts dental needs, the facility provided a receipt for purchase of dentures for resident #75 dated 2/28/11 with a balance forward from 1/31/11. However, there was no evidence in the clinical record or by interview that the facility had followed up with resident #75 to ensure proper fit of the dentures. Further, while several facility staff acknowledged they were aware resident #75 had no teeth, there was no evidence in the clinical record or in interview that anyone had asked resident #75 if he had difficulty chewing.",2017-01-01
7822,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2012-06-08,431,D,0,1,U80L11,"Based on observation, record review and interviews the facility failed to accurately reconcile and account for controlled medications in 1 of 2 facility medication storage rooms. Findings include: During review of the facility's medication storage on the Nutter Fort unit on 06/07/12 at 11:42 A.M., a clear locked box was discovered in the locked refrigerator located in the locked medication room. The clear box contained 2 clear zip lock bags. One bag contained 4 vials of Ativan (2 mg/ml), a benzodiazepine, and the other contained 2 vials of Ativan (2 mg/ml). There was also a cardboard box with a sticker that served as a seal to indicate if the card board box had been opened. Licensed Practical Nurse (LPN) #42 identified the box as a Hospice Kit. The box had been opened and was resealed with a piece of clear tape. A label on the box listed the contents of the box as having a bottle of Morphine Sulfate 30 ml at 20 mg/ml and 6 Ativan 0.5 mg tablets. The contents of the box was verified on 06/07/12 at 1:43 P.M., with the Director of Nursing and LPN #42. Review of the facility's policy titled Medication Management Guidelines: Narcotic Count, dated 08/11/06 revealed the purpose of the policy is to provide a guideline for the process of a physical inventory check (count) and documentation of controlled medications stored within the center. The guidelines of the policy state two licensed nurses are required for the performance of narcotic count on each unit. One licensed nurse from the off-going shift-responsible for handing off the medication cart/narcotic drawer keys and one licensed nurse from the on-coming shift responsible for accepting the medication cart/narcotic drawer keys. The guidelines also state the staff are to count each controlled medication using the following steps: use the designated pharmacy forms or Controlled Substance Charting Record to verify each medication and number of doses available. The on-coming nurse physically counts each narcotic on hand and verbalizes count to off-going nurse. The off-going nurse confirms the accuracy of the count reported by the on-coming nurse from documentation on each patient's designated pharmacy form or Controlled Substance Charting Record. When the narcotic count is completed and accurate both licensed nurses sign the Narcotic and Controlled Substance Shift-to-Shift Count Sheet or other center specified form in designated column by date and shift. Review of the narcotic reconciliation book for the Nutter Fort unit revealed a document titled Controlled Medication Utilization Record. This form listed the Hospice Kit and was absent for any reconciliation of on-coming licensed or registered staff and off-going licensed or registered staff. When asked where the Ativan vials were reconciled and accounted for, LPN #42 provided a book that contained reconciliation of the facility's emergency stock of medications. The only reconciliation entries on the document were 05/19/11, 07/12/11, 08/24/11, 10/18/11 and 05/31/12. The document was absent for any signatures of licensed or registered staff. During interview on 06/07/12 with LPN #82 and LPN #42 it was verified they do not reconcile the Ativan vials and the Hospice Kit every shift with the on-coming or off-going nurse. During interview on 06/08/12 at 11:57 A.M., with the facility Pharmacist it was verified the facility should be reconciling the ativan vials and the narcotics contained in the cardboard box labeled Hospice Kit every shift.",2017-01-01
7998,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2013-11-21,246,E,1,0,G1FX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, resident interview, staff interview, and record review, the facility failed to ensure reasonable accommodations of individual needs and preferences for the method of providing heat in resident's bathrooms and providing washcloths and towels for residents' use in toileting and hygiene were provided. Resident #92 was displeased with a new method of heating her bathroom. Although there was no evidence of problems with the previous heating device, the device was disabled and a new type of device installed. The facility had made some attempts to resolve this issue, but it had not been to the satisfaction of the residents. Additionally, towel racks had been removed, reportedly for sanitation reasons and the new system had not proven satisfactory to the residents. This was found to have the potential to affect more than an isolated number of residents. Resident identifier: #92. Facility census: 95. Findings include: a) Resident #92 This [AGE] year-old resident was admitted to the facility on [DATE]. Her Brief Interview for Mental Status (BIMS) score, as assessed on 09/27/13 was 15, indicating she was cognitively intact. Resident #92 was observed upon entrance on 11/19/13 at 5:00 a.m. She was sleeping in her recliner. Record review found that was her preference. She was later seen moving about the facility in her motorized wheelchair on several occasions. She was conversing amicably with staff and other residents. She was observed again in her room sleeping in her recliner on 11/20/13 at 8:50 a.m. On 11/19/13 at 10:05 a.m., the temperature in her bathroom was measured as 82 degrees Fahrenheit (F), and the temperature in her room at 84 degrees Fahrenheit. Resident #92 was interviewed on 11/20/13 at 10:12 a.m. She was asked about any concerns. She began with the infrared heat lamps in her bathroom. She said they had been installed to replace the [MEDICATION NAME] wall heaters that had been in service for the seven (7) years she has been in the facility because someone said the wall units were not safe. She said I don't like a heat lamp. I will never accept a heat lamp. They are not safe. She related she had been a property manager for the Department of Housing and Urban Development (HUD). She said there was an old lady in one of the apartments who was sitting at her table under a heat lamp who got burned on the back of her neck and she did not even know it. The lady had gotten a big blister on her neck and back, and she had to drive the lady to the emergency room for treatment. She said I'm afraid of them. She said when they first put them in, they were on a timer. The timer switch was on the wall and you had to turn it when you were going in the room. She said I have poor vision, I couldn't see to turn it on, and nobody offered to show me how to do it. She had a care plan in place for impaired vision which stated (typed as written): Impaired vision as evidenced by her need for magnifying glass for reading small print related to Disease processes and Diabetic Retinopathy. Date Initiated: 3/27/2007 Created on: 3/27/2007 Revision on: 11/6/2012 She said someone turned it on one time and it was on so long by the time she went in the bathroom it burned her face. She said then they put a motion sensor switch on. She said It sounds very modern and very wonderful, but it's nothing of the sort. It does come on when you walk in the room, but doesn't even begin to heat up the space until you are already out. Review of complaints documented by the facility found a complaint made by Resident #92 dated 09/23/13 regarding bathroom heaters that was addressed on 10/04/13 as follows (typed as written): Regional manager of Plant Operations visited on 10/4/13 to discuss options with resident. Currently have motion censored switch to see if adequate for resident. Monitoring temperatures at this time. A follow-up note by the administrator, Employee #117, dated 10/12/13, stated Follow-up to concern, resident stated she would not be happy until the old heater was hooked back up. Continued education on the safety concern of the heater. Asked her if she was open to other options for heaters and she stated only wanted the 'old heaters back'. Will refer to Plant Operations Manager if we can explore other options. Observation during the interview found that the motion sensor had been replaced at some point by a thermostat, which had a pencil line drawn at around seventy-four (74) degrees Fahrenheit. When advised of this change, she denied that the motion sensor had been replaced. She said she had been told by Social Workers, Nurses, and even the Administrator recently that if she is not happy here, to move to another facility. She said she has been here for seven (7) years, had very poor vision, and she now knows her way around the place, she is not going anywhere. She said the facility then told her the State Fire Marshall told them they had to remove the old heaters. She called the State Fire Marshall and he had never heard anything about it. Then the local Fire Marshall, (name) came to her room accompanied by the maintenance director and the administrator. He said the wall heater could burn her if she fell against it. She told him that when she falls, she usually falls down, not up. The heater was located six feet up on the wall. He then said she could accidentally get her hand or arm up against it and get burned. She said that was what the grate over the elements was for. He said he would go in and check it out. He went in the bathroom with the maintenance supervisor for around ten minutes, came out and said that proves it, if I had left my hand there any longer, I would have been burned. She pointed out that the power to this heater had been disconnected six months earlier. The facility said they have no choice but to follow what the Fire Marshall says. She said she has been in the room for seven (7) years, and never burned herself on the wall unit. She said the wall heater in the main part of her residence does not provide heat to the bathroom because the bathroom door opens out against it, blocking the heat. She said the door gets so hot from the heater that she figures it could burn you if you put your hand on it. She said They have the mind-set that when you come to a nursing home, you no longer know anything. You're not supposed to reason and think. You're not supposed to ask questions, you're just supposed to mindlessly go along with whatever they say. I'm just not going to do it. The maintenance supervisor, Employee #87, was interviewed on 11/20/13 at 1:55 p.m. He addressed the issues pertaining to the wall heaters, which he said began about one (1)year ago, with a visit from a regional vice-president of the corporate owner of the facility. He used the men's visitor's restroom and was concerned about the wall heater being a possible burn hazard. In order to remove that hazard, it was decided to disable the unit and install overhead heat lamps as an alternative. Although Employee #87 was not aware of the decision making process, he said that at some point, he was instructed to perform the same renovation for all of the resident rooms equipped with the old style [MEDICATION NAME] wall units. Only bathrooms with exterior walls were equipped with those units because they were needed for additional heat. The corporation specified that they be controlled by timers that would be limited to thirty (30) minutes of operation time. He said that in practice, this system did not work out, because residents who independently went to their bathrooms turned on the timer, but the room did not actually get warm until they had already gone back to their bed or chair. Because of Resident #92's complaints that she was unable to operate the timer due to visual limitations, the timer was replaced with a motion sensor in her room only. Following being advised of citations due to inadequate temperatures found during a complaint survey in September of this year, a decision was made recently to replace all the timers and the motion sensor in room [ROOM NUMBER] with thermostats to more effectively maintain comfortable temperatures in the rooms with exterior walls. He was asked about the involvement of the Fire Marshal. He said that Resident #92 called the State Fire Marshal's office and reported that her face had been burned by the heat lamp in her bathroom. The State Fire Marshal instructed the local Fire Marshal to investigate the issue and he came to the facility on [DATE]. He said after hearing Resident #92's concerns, he turned the ceiling mounted heat lamp on, and held his hand up near it to see if it could have reasonably cause [MEDICAL CONDITION] her face. He said he could not conduct any tests on the wall mounted unit because it was disconnected. He said that the Fire Marshal said he could not comment on whether the original wall unit she wanted hooked back up was unsafe. The Fire Marshal advised them to contact the Life Safety program of the Office of Health Facility Licensure and Certification (OHFLAC) to see if they might restore the room to using either the wall unit still in place or install a similar, newer unit. He said the Fire Marshal informed them he would submit his findings to his State Office, and a report would be sent to the facility. He said he had not received any report yet. He did not know if administration had made any contact with Life Safety regarding using a wall unit in room [ROOM NUMBER] to accommodate the resident's fears, concerns, and preferences. He was asked if he would check on the availability of the report. He returned in a few minutes with the report. He said the administrator had it. Review found a complaint inspection was conducted on 10/15/13 by the local Fire Marshal accompanied by the administrator the maintenance director, and Resident #92. The narrative from the investigation stated (typed as written): Complaint Inspection limited to possible heating condition to room [ROOM NUMBER] only. On this date I spoke with those in the accompanied section of the report about the complaint received by this office to a possible heating condition to room [ROOM NUMBER]. Ms. (name)'s complaint is she apparently believes that the newly installed electric heat system installed in the ceiling is causing the room to have temperatures above her comfort level. Heater is installed in the bathroom and she believes it is causing not only the bathroom but her dwelling unit to be affected. I spoke with staff representatives who stated they were and are going to be conducting on going temperature monitoring for Ms. (name)'s room. They stated they would keep a temperature log which would be available for review. I told staff to contact the State Health Dept. as well. At time of this inspection, the room's temperature & current log appeared to have normal readings. The maintenance director said the wall units could be put back in service simply by re-attaching the wires which had been disconnected. He was asked to provide a floor plan showing the rooms with exterior bathroom walls and [MEDICATION NAME] wall units. He provided the plan, and it showed there were twenty-six (26) rooms with the wall units in the facility. The administrator, Employee #117 was interviewed on 11/20/13 at 4:36 p.m. She agreed with the account as previously described by the maintenance supervisor. She agreed that Resident #92 had capacity and was acting as her own decision-maker for all areas of medical treatment, dietary choices, advance directives, every other area of her life choices. She said she had not made any attempt at contact with Life Safety regarding the possibility of reconnecting the existing wall unit or installing a similar new unit in its place to accommodate the resident's preference. b) A review of the facility's complaint files and resident council meeting minutes for the previous three (3) months was completed on 11/20/13 at 12:27 p.m. This review found two (2) individual complaints that towel racks had been removed from resident rooms. Resident council minutes for 11/03/13 included under new business Towel rack issue. One (1) of the individual complaints was made by Resident #92 on 11/06/13. It said Resident wants towel bars back in her room. During the interview of 11/20/13 at 10:12 a.m., she was asked about her concern that her towel rack had been taken away. Observation found that there was a rack with towels on it in her bathroom. She confirmed that they had been returned recently. She said when they had taken them away they said it was due to infection control concerns that other residents would accidentally use the wrong towels and that would cause a risk of cross contamination. She said that may be so, but she was in a private room. When they placed folded towels on her bedside stand or over bed table, she could not see well enough to find them, and often knocked them on the floor or even into her wastebasket, and that was a bigger infection control risk than having them on a towel rack in a private room with only one person using them. She said sometimes they just put them at the foot of the bed, and she did not think that was a sanitary practice either. After her repeated complaints, the facility had restored the towel rack because she was in a private room. The other individual complaint was made by Resident #65 on 10/25/13. It said Concerned that towel rack was removed from bathroom and she has to ask for towels/washcloths every morning. She was interviewed on 11/21/13 at 10:45 a.m. She was asked about the situation with her towels and washcloths. She said she has no idea why they took the towel racks out. She said You have to ask for towels or washcloths, and you're never sure if you'll even get them. Sometimes there is just nothing to wash with or dry off with. She said she had complained, . but they haven't done a thing about it. Random observations were made on 11/21/13 at 9:30 a.m. There were no towels or washcloths found anywhere in rooms 400, 403, 411, 409, 301, 117, 114, or 207. None of the rooms had a towel rack in the bathroom. The entire process on both wings from 9:30 a.m. to 10:45 a.m. Nursing assistants were interviewed during these observations as they were encountered throughout the facility. Several of the nursing assistants asked not to be identified due to fear they would face retaliation from the facility for speaking with surveyors. None of the nursing assistants will be identified due to these requests, but simply numbered in order of the conversations. They were all asked to explain their understanding of the removal of the towel racks and what they were told to do after they were taken away. Nursing assistant #1 said he/she had no idea why they were removed. He/she said now they bring out one (1) set of towels and washcloths and place them folded at the foot of the beds. He/she said they often get knocked off onto the floor. When they are used by a resident, they are supposed to leave them in the bathroom, and the nursing assistant is supposed to place them in the soiled linen containers. He/she said they only bring them out at the beginning of the shift. They do not replace them if they are used. They did not believe afternoon shift or night shift brought out any additional towels or washcloths for the residents. Nursing assistant #2 gave the same explanation, further stating that if they had no washcloth or towels, they would have to use paper towels I guess. Nursing assistant #3 said they only give residents washcloths and towels if they ask for them. They do not routinely bring any to them on any shift. If they are used, they place them in the dirty linen carts. Nursing assistant #4 agreed this was the procedure, and said that some residents asked for them, then hoard them by sticking them in closets, cabinets, or wherever they think they will not be discovered. The administrator, Employee #117, was asked on 11/21/13 at 11:00 a.m. to explain how the decision was made to remove the towel bars from resident's bathrooms. She said she was not sure. Someone from the corporate office had come to the building and implemented it. She said she and the director of nursing became aware of it when they saw maintenance removing all the racks from the bathrooms. She was asked for any documentation of any disservices or instruction that may have been provided to the nursing assistants for what they were supposed to do after the towel racks were gone. The director of nursing, Employee #54, provided some documents on 11/21/13 at 11:15 a.m. There was a paper with the heading In-service that stated: (typed as written): Residents are to be provided with a wash cloth and towel at the beginning of day shift. Place towels and wash cloths on resident bedside table for am (morning) use & per resident request. When residents are done with items bag linens and place in laundry barrels. Do not leave excess linens in resident rooms. There were sign-in sheets for 10/31/13 and 11/07/13. A total of twenty-four (24) of the sixty (60) nursing assistants, both employees and contracted agency identified as current staff by the facility signed indicating they had been instructed in the procedure. The first documented complaint, from Resident #65, was dated 10/25/13. No guidance had been provided to any of the nursing assistants for at least seven (7) days after the towel racks were removed. There was no evidence that residents were ever informed of the change prior to implementation and given any explanation or opportunity to have input prior to the removal of the towel racks.",2016-11-01
7999,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2013-11-21,514,D,1,0,G1FX11,"Based upon record review and staff interview, the facility failed to maintain clinical records that could provide accurate documentation of implementation of the plan of care and the services provided to ensure adequate hydration for a dependent resident. This was found for one (1) of three (3) residents reviewed. Resident identifier: #1. Facility census: 95. Findings included: a) Resident #1 The facility was entered on 11/19/13 at 4:55 a.m. A general tour of the entire facility was immediately undertaken. Information was requested from administrator, Employee #117 regarding residents ordered thickened liquids. Upon review, on 11/19/13 at 9:41 a.m., it was found three (3) residents were ordered thickened liquids. These residents were #1, #56, and #87. Resident #56 had documentation that fluids were offered on the night of 11/18/13 - 11/19/13 at 22:18 (10:18 p.m.) and at 10:36 a.m. Resident #87 had documentation that fluids were offered on the night of 11/18/13 - 11/19/13 at 6:18 a.m. and 1:47 a.m. There was no field found in the electronic medical record (EMR) for the nursing assistants to document that fluids were provided to Resident #1. The resident's care plan included (typed as written): Potential for skin breakdown, inadequate oral intake, and weight loss r/t (related to) . and limited mobility, swallowing difficulty AEB (as evidenced by) chart and pt interview/review, and puree with spoon thick liquids. Date Initiated: 3/2/2011 Created on: 3/2/2011 Revision on: 8/28/2012. The facility administrator, Employee #117 was interviewed on 11/19/13 at 10:47 a.m. She said that based upon her care plan, her expectations for Resident #1 would be that fluids would be offered with meals and between meals on all shifts due to her inability to hydrate herself or effectively ask for fluids. She acknowledged there was currently no method in the EMR (electronic medical record) to permit the nursing staff to document when they provided Resident #1 with fluids by spoon feeding thickened liquids in between meals and at night. On 11/20/13 at 10:56 a.m., it was found that a new field had been created in the EMR for the staff to document that stated (typed as written): Pudding thick Fluids offered and no straw (DOC)",2016-11-01
8084,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2013-10-24,224,E,1,0,3OEW11,"Based on record review, staff interview, and review of facility complaints and concerns, the facility failed to develop and implement policies and procedures which ensured four (4) of sixteen (16) residents reviewed were free from neglect by nursing personnel. Agency personnel were not provided orientation or supervision to ensure residents were not neglected due to lack of knowledge regarding the care and services which were necessary to meet the needs of each resident. This affected Residents #68, #99, and #18. In addition, the care for Resident #3 was not monitored to ensure he/she was not neglected. The assigned nursing assistant (NA) left the premises and no one was reassigned to care for the resident. Resident identifiers: #68, #99, #18, and #3. Facility census: 100 Findings include: a) Resident #68 Review of the concern forms, on 10/01/13 at 9:57 a.m., revealed a concern from this resident dated 08/30/13. The resident asked for the bed pan and a nursing assistant (NA) told her to just go in her brief, and she would change her. The NA wrote a statement confirming this had occurred. Review of the corrective action for the incident revealed documentation which stated inadequate training. It also contained a note which read, Great need to give oversight to agency staff to ensure the plan of care was carried out appropriately. b) Resident #99 Review of the concern forms, on 10/01/13 at 8:55 a.m., revealed an allegation the resident did not receive a shower for four (4) days. The concern, dated 08/14/13, indicated staff told the resident they would give her a shower, and did not return. The incident was investigated and substantiated. According to the report, the agency NA documented she provided care, but did not. c) Resident #18 Resident #18 alleged, on 08/29/13, Employee #38 (NA) and Employee #131 (agency NA) had not changed his brief since the previous morning. Employee #38 (NA) was educated on 08/30/13 to check the Kardex daily. She had worked the 3-11 shift. The agency NA, was responsible for the provision of services between 11:00 p.m. and 7:00 a.m. In her statement, she said she had not received training, and was not aware the resident required check and change every 2 hours. d) An interview with the director of nursing (DON), on 10/24/13 at 8:00 a.m., revealed no written information was provided to agency NAs prior to provision of care. She said they made rounds with the nursing assistants, and that was the orientation. The DON said the facility did not have a policy regarding the utilization of agency services and/or training needs. She further added, no form or checklist was utilized to ensure the agency nursing assistants and/or nurses received the information required to care for the residents. e) An interview was conducted with Employee #147 (agency NA) and Employee #154 (agency NA), on 10/24/13 at 4:30 p.m. Employee #154 said she didn't really get any training when she started working at the facility. She said she .would get a run down on the residents. The NA described a run down indicated transfer and toileting status, turn every two (2)hours and other activity of daily living information. Employee #147 said, I got no training. They said here is your assignment, go. f) On 10/23/13, at 8:30 a.m., Employee #127 (administrator) provided concern forms, which she said had generated from a meeting (called resident council) with the ombudsman on 09/23/13. They included resident concerns with staff turnover and agency staff attitudes. g) Resident # 3 Review of a mandatory reporting form, on 10 /24/13 at 1:00 p.m., revealed Resident #3 who resided on the Nutter Fort Hall, was left soaking wet (incontinent of urine) from 7:00 p.m. to 9:00 p.m. on 09/24/13. The daily assignment sheet, reviewed on 10/24/13 at 1:10 p.m., revealed Employee #64 was assigned to Resident #3 from 3:00 p.m. to 11:00 p.m. on 09/24/13. Review of the time detail, on 10/24/13 at 3:30 p.m., revealed Employee #64 left the facility at 7:00 p.m. on 09/24/13. An interview was conducted on 10/24/13 at 4:45 p.m., with Employee #136, a nurse supervisor licensed practical nurse (LPN). When asked who provided care for Resident #3 after Employee #64 left the facility, she stated no one was responsible for caring for this resident from 7:00 p.m. until around 8:30 p.m. She stated an NA from Jackson Hall was asked to come to Nutter Fort hall to help around 8:30 p.m. that night. On 10/24/13 at 3:35 p.m., review of a progress note for 09/24/13 revealed Employee #46, an LPN, changed Resident #3 at 9:00 p.m. The noted stated Resident #3 had been left soaking wet. During an interview on 10/24/13 at 4:10 p.m., with Employee # 55 , DON, when asked who provided assistance to Resident #3 on 09/24/13 from 7:00 p.m. to 8:30 p.m., she confirmed no one provided care for the resident during this time period.",2016-10-01
8085,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2013-10-24,242,D,1,0,3OEW11,"Based on record review, observation, and resident interview, the facility failed to ensure one (1) of ten (10) sample residents had the opportunity to make choices regarding an important aspect of her life. The resident was not served foods which were assessed as preferences, and was served foods which were assessed as dislikes. Resident identifier #96. Facility census: 100. Findings include: a) Resident #96. Observation on 09/30/13 at 5:30 p.m., revealed Resident #96 received green beans, a chicken breast, and apricots. The resident did not touch her food. Upon inquiry, the resident stated that she did not like chicken. Review of resident's likes and dislikes, on 09/30/13 at 5:35 p.m., revealed this resident disliked chicken, yet she received chicken for her meal. Her likes included salad, but she did not receive a salad. An interview was conduced with Employee #127, the administrator, on 10/01/13 at 9:30 a.m. When asked if Resident #96 should have have received chicken if it was noted as a food dislike, and why did the resident not receive a salad if she liked salads, the administrator confirmed the resident should have not received chicken and should have received a salad.",2016-10-01
8086,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2013-10-24,252,E,1,0,3OEW11,"Based on observation and staff interview, the facility failed to maintain a safe, homelike environment. Over-the-bed tables and linen carts were stored in the shower room. This practice had the potential to affect more than a limited number of residents. Facility census: 100. Findings include: a) Shower room During a tour of the facility on 10/01/13 at 1:30 p.m., the central shower with the whirl pool on the 300 hall was cluttered with over-the-bed tables and other items. Soiled linen carts were lined throughout the bathroom corridor, and in the shower stalls. The entry was unavailable to the whirlpool area, because it was blocked by the tables and carts. The two (2) shower areas contained bath chairs and linen carts. Two (2) staff members were observed unable to pass each other due to the linen carts in their way. An interview with Employee #77, a nursing assistant, at 6:20 p.m. on 09/30/13, revealed the shower room was routinely utilized for bathing. On 10/01/13 at 6:15 p.m., during an observation of the shower room with Employee #55, the director of nursing (DON), she agreed the shower room on the 300 hall had too much storage. The DON said it should not be used as a storage room. She stated the over-the-bed tables were not to be stored in the bathroom. The DON also acknowledged egress in and out of the shower rooms would be impeded due to items blocking the entrance/exit. Upon inquiry, the director of nursing confirmed a wheel chair could not be taken in or out of the room without moving the carts.",2016-10-01
8087,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2013-10-24,257,E,1,0,3OEW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and review of a facility audit, the facility failed to ensure temperatures throughout the facility were within a range acceptable to the residents and/or at least 71 - 81 degrees as required. Temperatures in rooms and/or bathrooms in rooms 402, 409, 411, 415, 105, 200, 402, 415, 417, and the shower room on the 200 hall were not maintained between 71-81 degrees Fahrenheit. This had the potential to affect more than an isolated number of residents. Facility census: 100. Findings include: a) Resident #36. During an interview with Resident #36 on 10/24/13 at 3:50 p.m., when asked about the comfort of his room, he stated his room was very cold that morning. He stated the heat was just turned on in his room that afternoon, and it now was more comfortable. b) Resident #98 During an interview with Resident #98, on 10/23/13 at 8:40 a.m., she said she thought the bathroom was cold. She acknowledged It warms with the heater, but not fast enough for me. The maintenance supervisor (Employee #94) provided a list of temperatures taken on 10/23/13, between 2:30 and 3:30 p.m. He noted the temperature for the bathroom was 70.1 degrees. Employee #94 acknowledged the temperature should be at least 71 degrees, but confirmed comfort must be gauged by the resident's perception. c) An interview was conducted on 10/24/13 at 4:00 p.m. with Employee #94, the director of maintenance. When asked when the heat was turned on in residents' rooms, he stated he turned on the heat in the rooms when doing his checks if he felt like it was cold in the rooms. Employee #94 stated staff also turned on the heat for residents who were unable to tell you they were cold, if the staff member felt like it was cold in the room. He stated he was responsible for turning on the heat for the shower rooms and the halls whenever he thought it was cold. During an interview with Employee #103, a nursing assistant, on 10/24/13 at 3:55 p.m., when asked how the heat was turned on (or up) in the residents' rooms, she stated if she felt cold she turned up the heat in the rooms. Employee #102 said the maintenance department was responsible for turning on the heat throughout the facility at a certain time. Interviews were conducted on 10/24/13 at 3:56 p.m., with Employees #95 and #1, both nurse supervisor licensed practical nurses (LPN). Upon inquiry, regarding how they determined heat in residents' rooms required adjustment, both employees stated they adjusted the heat when they felt like it was cold in the room. Each of the LPNs stated they were cold all the time. These staff interviews indicated the determinations to adjust the heat in resident rooms and common areas were based on opinions of staff, instead of the residents, in determining whether the areas were comfortable. d) A review was conducted, on 10/24/13 at 10:00 a.m., of the facility audit tool for measuring temperatures. This tool contained room temperatures taken between 2:30 p.m. to 3:00 p.m. on 10/23/13: Temperatures below the required minimum of 71 degrees Fahrenheit included: --room [ROOM NUMBER] = 70.9 degrees, bathroom [ROOM NUMBER].1 degrees --room [ROOM NUMBER] = 69 degrees, bathroom [ROOM NUMBER] degrees --room [ROOM NUMBER] = 67 degrees, bathroom [ROOM NUMBER] degrees -- room [ROOM NUMBER] = 70.5 degrees, bathroom [ROOM NUMBER].1 degrees --room [ROOM NUMBER] bathroom = 69.1 degrees --room [ROOM NUMBER] bathroom = 70.9 degrees --room [ROOM NUMBER] bathroom = 69.1 degrees --room [ROOM NUMBER] bathroom = 69.1 degrees --room [ROOM NUMBER] bathroom = 70.1 degrees --200 hall shower 66.9",2016-10-01
8088,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2013-10-24,353,E,1,0,3OEW11,"Based on record review and staff interview, the facility failed to deploy staff in a manner which ensured the needs of each resident were met. Two (2) nursing assistants, who were assigned the residents in twelve (12) rooms, left the facility. Staff was not reassigned to provide care for these residents for at least one and one-half (1 and 1/2) hours. One resident was affected; however, this practice had the potential to affect more than an isolated number of residents. Resident identifier #3. Facility census: 100. Finding include: a) Resident #3 Review of a progress note, on 10/24/13 at 3:35 p.m., revealed on 09/24/13, Employee #46, the nurse supervisor LPN, documented on 09/24/13 she went in to change Resident #3 at 9:00 p.m., because she had been left soaking wet. The LPN stated the bed had to be completely changed. Review of the five day follow-up note regarding this incident revealed the assigned nursing assistant for Resident #3 left the facility without notifying the charge nurse. b) Rooms 307, 308, 309, 310, 311, 312, 400, 401, 402, 416, 417, and 419 Review of the 09/24/13 daily assignment sheet, on 10/24/13 at 1:10 p.m., revealed Employee #64, a nursing assistant, was assigned to rooms 307, 308, 309, 310, 311, and 312 on 09/24/13. Review of the time detail, on 10/24/13 at 3:30 p.m., revealed Employee #64 left the facility at 7:00 p.m. on 09/24/13. Employee # 41, a nursing assistant, was assigned to rooms 400, 401, 402, 416, 417, and 419 09/24/13. Review of the time detail, on 10/24/13 at 3:30 p.m., revealed Employee #41 left the facility at 6:59 p.m. on 09/24/13. The nursing staff list, reviewed on 10/24/13 at 4:00 p.m., revealed on 09/24/13 three (3) nursing assistants, Employees #29, #105, and #40 from the Jackson hall, were assigned to assist with the Nutter Fort hall from 8:30 p.m. to 10:30 p.m. There was no one deployed to take the resident assignments for Employee #41 (NA) who left at 6:59 p.m. or Employee #64 (NA) who left at 7:00 p.m. until 8:30 p.m. An interview was conducted, on 10/24/13 at 4:45 p.m., with Employee #136, nurse supervisor licensed practical nurse (LPN). When asked who provided care for these residents in rooms 307, 308, 309, 310, 311, 312, 400, 401, 402, 416, 417, and 419 after Employees #64 and #41 left the facility, she stated no one was caring for these residents from 7:00 p.m. until around 8:30 p.m. She said nursing assistants from Jackson Hall were asked to come to Nutter Fort hall to help around 8:30 p.m. that night. On 10/24/13 at 4:10 p.m., an interview was conducted with Employee # 55, the director of nursing (DON). When asked who provided assistance to the residents on 09/24/13 from 7:00 p.m. to 8:30 p.m., she confirmed no one provided care to the residents in rooms 307, 308, 309, 310, 311, 312, 400, 401, 402, 416 ,417, or 419 on 09/24/13 from the time the nursing assistants left around 7:00 p.m. until nursing assistants from Jackson Hall were asked to come over and provide assistance around 8:30 p.m. The DON stated when the nursing assistants left, the LPN nurse supervisor should have arranged the schedule to ensure the residents were cared for on Nutter Fort hall. She confirmed the LPN nurse supervisor delayed doing that from 7:00 p.m. until 8:30 p.m.",2016-10-01
8089,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2013-10-24,371,F,1,0,3OEW11,"Based on staff interview and facility record review, the facility failed to implement policies and procedures to ensure foods were prepared and served at the temperatures which reduced the potential for foodborne illness. Food temperatures for cold items were not monitored. This had the potential to affect all residents who received food from the kitchen. Facility census: 100 Findings included: a) Food temperatures On 10/23/13 at 3:00 p.m., dietary temperature logs and menus were reviewed for the months of July, August, September, and October 2013. The logs contained no temperature monitoring of milk beverages for the period of 10/01/13 through 10/23/13. In addition, correlation of the menus items served, with the food temperatures which were measured, revealed temperatures were not taken of potentially hazardous cold menu items such as chicken salad, macaroni salad, tuna salad, coleslaw, and egg salad. Employee #15 , the dietary manager, was interviewed on 10/23/13 at 3:30 p.m. She reviewed the temperature logs and confirmed temperatures had not been obtained for cold food items.",2016-10-01
8090,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2013-10-24,441,D,1,0,3OEW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, and policy review, the facility failed to maintain a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection. A garbage can was overflowing and an oxygen concentrator and briefs were stored improperly. Resident identifier: #92. Facility census: 100. Findings included: a) Resident #92 During a random observation, on 10/23/13 at 7:00 a.m , two (2) oxygen concentrators were observed next to Resident #92's bed, which was situated closest to the hallway door. The concentrators were positioned one in front of the other. Additionally, a recliner chair was positioned between the two (2) oxygen concentrators and the bed on the far side of the room. Upon inquiry, Resident #92 said one concentrator belonged to her, and one had belonged to her room mate. The resident added, She's at the hospital because she has pneumonia. Additionally, a urinal and a graduate were observed on the back of the commode. The urinal had a small amount of urine in it. An opened bag of disposable underwear was on the floor between the commode and the wall. Resident #92 offered, I don't know who's underwear those are. They aren't mine. Employee #55, the director of nursing (DON), was interviewed on 10/23/13 at 4:00 p.m. She completed a room observation during the interview, and confirmed the concentrator was stored improperly and posed a risk for cross contamination. She also stated staff could potentially utilize the room mate's concentrator for Resident #92, because it was beside her bed. In addition, she confirmed the briefs were stored improperly, posing a risk for cross contamination. She said, We'll remove those. Employee #55 also confirmed Resident #92's room mate had been admitted to the hospital. b) room [ROOM NUMBER] During another random observation, at 7:00 a.m. on 10/23/13, garbage was observed overflowing from the garbage can in the bathroom of room [ROOM NUMBER]. Garbage was piled about 12 inches above the can and was touching the wall beneath the sink. Paper towels were scattered on the floor, around the garbage can, and beneath the sink. An interview with Employee #27, a registered nurse (RN) supervisor, confirmed the garbage should have been emptied prior to overflowing, and had the potential for transmission of cross contamination and infection. The infection control manual was reviewed on the computer, on 10/23/13 at 4:00 p.m. Section 5, support services, noted bins, barrels and cans were to be emptied when three-fourths (3/4) full to prevent overflow. During an interview, on 10/23/13 at 4:00 p.m., the DON confirmed facility policy was not followed, presenting a potential for the spread of disease and infection.",2016-10-01
8091,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2013-10-24,490,F,1,0,3OEW11,"Based on record review, staff interview, and review of facility complaints and concerns, the facility was not administered in a manner which ensured the highest practicable physical, mental and/or psychosocial well-being of each resident Agency personnel were not provided orientation or supervision to ensure residents were not neglected due to lack of knowledge regarding the care and services which were necessary to meet the needs of each resident. This affected Residents #68, #99, and #18, but had the potential to affect all residents. Resident identifiers: #68, #99, and #18. Facility census: 100 Findings include: a) Resident #68 Review of the concern forms, on 10/01/13 at 9:57 a.m., revealed a concern from this resident dated 08/30/13. The resident asked for the bed pan and a nursing assistant (NA) told her to just go in her brief, and she would change her. The NA wrote a statement confirming this had occurred. Review of the corrective action for the incident revealed documentation which stated inadequate training. It also contained a note which read, Great need to give oversight to agency staff to ensure the plan of care was carried out appropriately. b) Resident #99 Review of the concern forms, on 10/01/13 at 8:55 a.m., revealed an allegation the resident did not receive a shower for four (4) days. The concern, dated 08/14/13, indicated staff told the resident they would give her a shower, and did not return. The incident was investigated and substantiated. According to the report, the agency NA documented she provided care, but did not. c) Resident #18 Resident #18 alleged, on 08/29/13, Employee #38 (NA) and Employee #131 (agency NA) had not changed his brief since the previous morning. Employee #38 (NA) was educated on 08/30/13 to check the Kardex daily. She had worked the 3-11 shift. The agency NA, was responsible for the provision of services between 11:00 p.m. and 7:00 a.m. In her statement, she said she had not received training, and was not aware the resident required check and change every 2 hours. d) An interview with the director of nursing (DON), on 10/24/13 at 8:00 a.m., revealed no written information was provided to agency NAs prior to provision of care. She said they made rounds with the nursing assistants, and that was the orientation. The DON said the facility did not have a policy regarding the utilization of agency services and/or training needs. She further added, no form or checklist was utilized to ensure the agency nursing assistants and/or nurses received the information required to care for the residents. e) An interview was conducted with Employee #147 (agency NA) and Employee #154 (agency NA), on 10/24/13 at 4:30 p.m. Employee #154 said she didn't really get any training when she started working at the facility. She said she .would get a run down on the residents. The NA described a run down indicated transfer and toileting status, turn every two (2)hours and other activity of daily living information. Employee #147 said, I got no training. They said here is your assignment, go. f) On 10/23/13, at 8:30 a.m., Employee #127 (administrator) provided concern forms, which she said had generated from a meeting (called resident council) with the ombudsman on 09/23/13. They included resident concerns with staff turnover and agency staff attitudes.",2016-10-01
8152,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2013-09-06,166,D,1,0,8W2H11,"Based on medical record review, staff interview, an interview with a representative from the West Virginia advocates, and resident interview, the facility failed to ensure one (1) of five (5) residents received medically-related social services. Resident #99 had filed a complaint with the West Virginia Advocates' office. The facility had not responded to this complaint after being contacted by the West Virginia Advocates office. Resident identifier: #99. Facility census: 104. Findings include: a) Resident #99 On 09/03/13 at 3:00 p.m., an interview with Resident #99 revealed she had filed a grievance with the West Virginia Advocates because she wanted a motorized wheelchair and felt the facility had not acted upon her request. On 09/04/13 at 4:00 p.m., the social workers (Employee #129) (Employee #137) both stated they did not know anything about a grievance filed by Resident #99 with the West Virginia Advocates. On 09/04/13 at 4:15 p.m. Employee #137 presented a packet of information from West Virginia Advocates. She said she did not know anything about the information in the packet. On 09/04/13 at 5:00 p.m., the administrator (Employee #127) said she had a lot of turn over in employees in the social service department. She acknowledged the facility had received the grievance from the West Virginia Advocates on 07/22/13 regarding Resident #99's request for a power chair for mobility. She said she did not know why the facility had not responded to this grievance, but verified they had not.",2016-09-01
8872,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2013-03-28,461,D,1,0,RM7211,"Based on resident interview, family interview, observation, and staff interview, the facility failed to provide individual closet space for one (1) of ten (10) sampled residents. Resident Identifier: #37. Facility Census: 10. Findings include: a) Resident #37 During an interview with Resident #37,and her friend (power of attorney), on 03/27/13 at 5:30 p.m., the resident said she shared her closet with her roommate. She related she only had one fourth portion of the closet space. Her friend opened the closet and separated Resident #37's possessions from the roommate's. No divider was present. Employee #89 (maintenance supervisor) was interviewed on 03/28/13, at approximately 1100 a.m He looked in the resident's closet and said a divider should have been present. He separated Resident #37's belongings in the closet, from the roommate's, and agreed the resident only had one fourth the closet space.",2016-03-01
9400,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,156,B,0,1,85AT11,"Based on record review and staff interview, the facility failed to assure one (1) of one (1) applicable resident / responsible party was informed of the right to request a demand bill when the resident's Medicare-covered services were discontinued by the facility. This practice had the potential to affect any resident who was discontinued from Medicare-covered skilled services. Resident identifier: #60. Facility census: 97. Findings include: a) Resident #60 On 04/07/10 at 3:30 p.m., a review was conducted, with the facility's business office manager, of residents whose Medicare-covered skilled services had been discontinued by the facility. Three (3) of four (4) residents reviewed had met their rehabilitation potential and were discharged home. One (1) resident (Resident #60) was discontinued from Medicare-covered services but remained in the facility. He had not exhausted his allowable one hundred (100) Medicare days, but facility staff believed he had met his rehabilitation potential. Because of this, he should have been offered the opportunity to request a demand bill. Review of the notice provided to the resident revealed the form did not contain an option for the resident / responsible party to request a demand bill. There was a space to indicate no regarding submission of a demand bill, but no space to indicate yes requesting the facility to submit a demand bill. In an interview conducted with the social worker (Employee #103) at 4:00 p.m. on 04/07/10, Employee #103 stated she had no idea how this situation had happened but confirmed the form did not contain the required information to allow a resident / responsible party to request the facility submit a demand bill in the resident's behalf.",2015-11-01
9401,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,272,E,0,1,85AT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, observation, and staff interview, the facility failed to periodic pain assessments for one (1) of thirty-seven (37) Stage II sample residents, and failed to complete accurate assessments for three (3) of thirty-seven (37) Stage II sample residents, all of whom were erroneously coded as being on planned weight change programs. Resident identifiers: #55, #160, #111, and #94. Facility census: 97. Findings include: a) Resident #55 In an interview conducted at 3:00 p.m. on 04/06/10, Resident #55 stated he had pain in his left leg and that it often kept him awake at night. At that time, the resident was observed rubbing his left thigh. The resident's medical record, when reviewed on 04/07/10, contained a current physician's orders [REDACTED]. Based on this order, facility staff should have been aware of the possibility of leg pain and should have provided ongoing assessments for this resident's specific pain. Review of the care plan, at the same time, revealed no care plan or other mention of leg pain. In an interview at 10:45 a.m. on 04/07/10, a registered nurse (RN - Employee #136) revealed she had no knowledge of the resident experiencing left leg pain. Employee #136 reviewed the resident's pain scores (pain assessments) for April 2010 and reported there was no documentation of pain thus far in April. She confirmed that the pain score record did not specifically indicate assessment of left leg pain. Employee #136 then visited the resident in his room. At 11:00 a.m. on 04/07/10, the RN reported the resident stated to her that he has left leg pain at night and that the leg pain kept him awake at night. The resident's care plan was again reviewed, this time with Employee #136. At 5:30 p.m. on 04/07/10, Employee #136 confirmed the facility was not aware the resident was having pain and confirmed that ongoing assessments for left leg pain had not been occurring for this resident. Employee #136 stated she would assess the resident and implement appropriate interventions. The following morning, another interview was conducted with the resident, at 9:00 a.m. on 04/08/10. He stated he had been given pain medication for his leg pain last night and that it had really helped. He stated, I slept like a log. b) Residents #160, #111, and #94 1. Resident #160 Medical record review, on 04/05/10, revealed an inaccuracy in information documented on the Resident #160's most recent minimum data set (MDS) assessment. In Section K of the MDS with an assessment reference date (ARD) of 03/10/10, the assessor recorded the resident was on a planned weight change program in the last seven (7) days. Review of the registered dietitian (RD) progress notes, dated 02/24/10, identified this resident's current weight was 156#, which was within the ideal body weight range for the resident's height (150# to 170#). There was no evidence the resident required a planned weight change program. 2. Resident #111 A significant change in status MDS, with an ARD of 10/03/09, revealed the resident had no significant weight change and was not on a planned weight change program. A significant change in status MDS, with an ARD of 11/25/09, indicated the resident had a significant weight loss but was not on a planned weight change program. A Medicare 60-day / readmission MDS, with an ARD of 01/08/10, indicated the resident experienced another significant weight loss and was now on a planned weight change program. A quarterly MDS, with an ARD of 02/15/10, indicated no significant weight change had occurred and the resident was not on a planned weight change program. A review of the care plan for Resident #111 revealed that, on 11/10/09, the interdisciplinary care team identified a problem of weight loss due to a history of dysphagia with nursing interventions to encourage / assist and provide extra nourishment. This care plan was reviewed on 02/19/10, but there was no mention of the resident being on a planned weight change program, and there were no changes to the care plan in response to the assessor encoding the 01/08/10 MDS to indicate he was on a planned weight change program. A review of the RD's assessment revealed no planned weight change program for this resident. During an interview with Employee #8 at 9:00 a.m. on 04/07/10, she stated there were no facility policies or procedures for a planned weight change program and no criteria for indicating this on the MDS. Although she verified the 01/08/10 MDS indicated the resident was on such a program, she also verified there were no corresponding care plan changes or physician's orders [REDACTED]. 3. Resident #94 A review of the admission MDS, with an ARD of 12/18/09, revealed the resident was on a planned weight change program although she had not experienced a significant weight loss or gain. The quarterly MDS, with an ARD of 03/08/10, indicated that she was no longer on a planned weight change program, although she now had a Stage II pressure ulcer. The resident's current care plan did include interventions for meeting nutritional needs, but there were no differences in the care plan before or after the MDS said the resident was on a planned weight change program. There was no evidence in the record to reflect the RD had developed a planned weight change program, nor were there any physician's orders [REDACTED]. During an interview with Employee #8 at 9:00 a.m. on 04/07/10, she stated there were no facility policies or procedures for a planned weight change program and no criteria for indicating this on the MDS. She stated she did not understand that there needed to be written guidelines. 4. According to The RAI Version 2.0 User Manual, page 3-154 states: h. On Planned Weight Change Program - Resident is receiving a program of which the documented purpose and goal are to facilitate weight gain or loss (e.g., double portions; high calorie supplements; reduced calories; 10 grams fat). There was no evidence to reflect Residents #160, #111, and #94 were actually on a planned weight change program (as defined by the RAI User Manual) during the assessment reference periods noted above.",2015-11-01
9402,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,279,E,0,1,85AT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, observation, and staff interview, the facility's interdisciplinary team (IDT) failed to develop care plans for four (4) of thirty-seven (37) Stage II sample residents, which contained information necessary to provide appropriate care and services to assist each resident in attaining or maintaining his/her highest level of functioning and/or well being. Care plans were not developed for pain, weight loss, or activities, based on the assessed medical, nursing, or psychosocial needs for these four (4) residents. Resident identifiers: #55, #100, #158, and #76. Facility census: 97. Findings include: a) Resident #55 In an interview conducted at 3:00 p.m. on 04/06/10, Resident #55 stated he had pain in his left leg and that it often kept him awake at night. At that time, the resident was observed rubbing his left thigh. The resident's medical record, when reviewed on 04/07/10, contained a current physician's orders [REDACTED]. Based on this order, facility staff should have been aware of the possibility of leg pain and should have provided ongoing assessments for this resident's specific pain. Review of the care plan, at the same time, revealed no care plan or other mention of leg pain. In an interview at 10:45 a.m. on 04/07/10, a registered nurse (RN - Employee #136) revealed she had no knowledge of the resident experiencing left leg pain. Employee #136 reviewed the resident's pain scores (pain assessments) for April 2010 and reported there was no documentation of pain thus far in April. She confirmed that the pain score record did not specifically indicate assessment of left leg pain. Employee #136 then visited the resident in his room. At 11:00 a.m. on 04/07/10, the RN reported the resident stated to her that he has left leg pain at night and that the leg pain kept him awake at night. The resident's care plan was again reviewed, this time with Employee #136. At 5:30 p.m. on 04/07/10, Employee #136 confirmed the facility was not aware the resident was having pain and confirmed that ongoing assessments for left leg pain had not been occurring for this resident. Employee #136 stated she would assess the resident and implement appropriate interventions. The following morning, another interview was conducted with the resident, at 9:00 a.m. on 04/08/10. He stated he had been given pain medication for his leg pain last night and that it had really helped. He stated, I slept like a log. b) Resident #100 Medical record review, on 04/05/10, revealed a nutritional status resident assessment protocol (RAP), dated 03/24/10, which triggered for leaving twenty-five percent (25%) or more of food uneaten and for being on a therapeutic diet. Goals discussed at that time included the need to slow / minimize weight loss and minimize risk factors. Review of the resident's comprehensive plan of care revealed that, once the IDT identified her potential for weight loss, they failed to develop an individualized plan of care to attain these goals. A dietary progress note, dated 03/26/10, identified she lost 6# in one (1) month, which was a four percent (4%) weight loss and three percent (3%) since admission. She was on a cardiac diet, her meal intake was 25-50 percent, and the registered dietitian (RD) recommended the nutritional supplement Ensure 4 ounces two (2) times a day to prevent further weight loss, although the order for this was not obtained until 04/01/10. A care plan note documented that a care conference was held on 03/31/10. In this meeting, the resident complained of not liking the food. She discussed with the dietary representative her current diet order and what changes could be made to improve her intake. Review of the care plan, located in binder at the nurse station, found no revisions had been made to her care plan after this conference occurred. On 04/06/10 at 3:23 p.m., the assessment coordinator (Employee #105), when interviewed, reviewed Resident #100's care plan in the computer system and acknowledged that no plan was developed to address the resident's altered nutritional status. On 04/05/10 at 3:34 p.m., the dietary manager (Employee #8), when interviewed, reported she was aware of the care plan meeting and, since then, they had started to place gravy on the foods in order to meet her needs. c) Resident #158 During Stage I of the survey, from 03/31/10 through 04/02/10, this resident was not observed attending / participating in facility activities, either in his room or at other sites within the facility. The resident's medical record, when reviewed on 04/07/10, disclosed the initial activity / recreation evaluation had been completed for this resident on 01/04/10, shortly after admission. The evaluation described the resident's activity / recreation interests, where and when the resident preferred activities, and the degree of assistance needed by the resident to participate in activities. The resident's daily activity / recreation participation record for March 2010 was requested and received from the activity director (Employee #124). The record provided evidence the resident attended activities on occasion. When reviewed on 04/07/10, the resident's care plan made no mention of activity / recreation problems, goals, or approaches for this resident. The assistant director of nurses (ADON - Employee #32), when interviewed on 04/07/10 at 11:30 a.m., stated the resident preferred to socialize with therapy staff and visit with family / friends in his room as opposed to attending structured facility activities. When questioned as to how facility staff would be aware of the resident's activity desires / plans, the ADON reviewed and confirmed the resident's current care plan made no mention of activities / recreational needs for this resident. d) Resident #76 During Stage I of the survey, from 03/31/10 through 04/02/10, this resident was not observed attending / participating in facility activities, either in her room or at other sites within the facility. The resident's medical record, when reviewed on 04/05/10, disclosed the initial activity / recreation evaluation had been completed for this resident on 03/12/10, shortly after admission. The evaluation described the resident's activity / recreation interests, where and when the resident preferred activities, and the degree of assistance needed by the resident to participate in activities. The resident's daily activity / recreation participation record for March 2010 was requested and received from the activity director. The record provided evidence the resident attended activities on occasion. When reviewed on 04/05/10, the resident's care plan made no mention of activity / recreation problems, goals, or approaches for this resident. On 04/05/10 at 10:00 am, a registered nurse (RN - Employee #50), who held the title of patient care coordinator and who was working in the Jackson Court area of the facility, was questioned as to the plan for this resident's activity / recreational needs. This RN reviewed the resident's current care plan and confirmed the plan contained no mention of the resident's activity / recreational needs.",2015-11-01
9403,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,280,D,0,1,85AT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed, for three (3) of thirty-seven (37) Stage II sample residents, to update the plan of care to reflect current needs. Resident #153 experienced a decline in urinary continence with no update to the plan of care, Resident #158 experienced a fall with no update in the plan of care, and Resident #160 experienced a change in the status and treatment of [REDACTED]. Resident identifiers: #153, #158, and #160. Facility census: 97. Findings include: a) Resident #153 The medical record for Resident #153, when reviewed on 04/07/10, disclosed the resident was admitted to the facility on [DATE]. According to the Nursing Admission Evaluation completed on 11/23/09, as well as the Bladder Pattering and Analysis Worksheet completed on 11/24/09, the resident was continent of bladder function. An ADL (activity of daily living) Worksheet, completed during the month of January 2010, continued to note the resident as being continent of bladder function. ADL Worksheets for the months of February, March, and April 2010 disclosed the resident had declined in urinary continence to the current status of totally incontinent. The resident's current plan of care, when reviewed on 04/07/10, noted a focus area for this resident as: Occasional urinary incontinence related to hypertonicity bladder, physical limitations. This focus area was initiated on 12/08/09, and included interventions such as using absorbant products and adult briefs and providing incontinence care as needed. The care plan had been reviewed on 03/01/10, but no changes had been implemented to reflect the decreasing urinary continence as described on the ADL Worksheets for the period of time after mid-February 2010 to the present April 2010, when the resident was described as being totally incontinent of urine. A licensed practical nurse (LPN) assigned to the care of this resident on 04/08/10 (Employee #119), when question as to the urinary continence of this resident, stated the resident was almost totally incontinent and would only occasionally ask to go to the bathroom. These findings were bought to the attention of the director of nurses (DON) and assistant director of nurses (ADON) on 04/08/10 at 10:00 a.m., and the facility could provide no evidence to reflect revisions had been made the resident's care plan to address her urinary incontinence. b) Resident #158 When reviewed on 04/01/10, the care plan for Resident #158, who was admitted to the facility on [DATE], disclosed the facility, on 01/13/10, identified the resident to be at risk for falls due to use of [MEDICAL CONDITION] medications, impaired balance / poor coordination, history of falls. Further review of the resident's medical record revealed [REDACTED]. The care plan was not updated at that time to reflect additional interventions to prevent further falls. The ADON (Employee #32), when interviewed on 04/07/10 at 11:00 a.m. about the resident's fall and interventions that had been implemented following the fall to prevent further falls, stated it was believed the resident's friend had attempted to assist him to transfer at the time of the fall. This friend had been educated at that time to call for staff assistance instead of attempting to help him herself. The ADON further confirmed the resident's current care plan did not contain any of this information to alert other staff caring for the resident about the problem should it happen again. c) Resident #160 Medical record review, on 04/05/10, revealed this [AGE] year old male was admitted to the facility on [DATE] with a Stage II pressure ulcer. On 02/23/10, the wound care clinic was consulted, since the wound was not showing any progression toward healing. On 03/23/10, the wound care clinic identified the needs to keep weight off the resident's coccyx at all times by using a waffle cushion in the wheelchair, to limit the amount of time sitting in a chair, and to reposition the resident every two (2) hours when in bed. Additional review of the medical record revealed the wound care clinic made several changes in the care / treatment of [REDACTED]. On 04/07/10 at 11:24 a.m., the dressing change procedure was observed, and the nurse reported the wound care clinic had changed the treatment to wash with soap and water, pat dry, and apply antifungal ointment. On 04/06/10 at 10:00 a.m., Resident #160, when interviewed in his room while in bed, reported he believed the wound care clinic had really helped, they had made several changes, to the treatment to be completed, and he had been told the ulcer was healing up pretty good. A review of the resident's comprehensive care plan, on 04/05/10, revealed the plan addressing the resident's pressure ulcer had not been updated to reflect changes in treatment made by the wound care clinic. Current care plan interventions included: apply skin care moisturizers as needed; encourage and assist as needed to turn and reposition frequently; evaluate and record wound status per facility guidelines until healed; observe for and report any evidence of infection such as purulent drainage, swelling, localized heat, increased pain etc.; Easy Air mattress to resident bed; supplements / enhanced or fortified foods per physician orders; and physical therapy referral and treatment as ordered by physician. On 04/10/10 at 3:26 p.m., the assessment coordinator (Employee #105), when interviewed, reported the wound care nurse was responsible for assessing the wounds and revising the care plans as needed. She identified the wound care nurse was off on sick leave and was not able to be interviewed at this time. On 04/07/10 at 9:30 a.m., the DON produced a copy of the facility's policy and procedure for wound healing. Review of this policy revealed that, on page 10 related to the comprehensive plan of care: Based upon the findings of the MDS, pressure ulcer RAP and other assessments, the initial care plan is updated and comprehensive care plan is developed. When the interdisciplinary team develops or updates the patients care plan a measurable goal is determined and a target date identified. Individualized interventions are selected based upon the current clinical condition risk factors, functional status and the patients values, goals and willingness to participate with the plan of care. The care plan is reviewed and updated to reflect the patients current status and care delivery needs, as clinically indicated and per state and federal regulations. There was no evidence the facility revised Resident #160 care plan as needed when changes in treatment occurred.",2015-11-01
9404,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,309,G,0,1,85AT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, record review, and staff interview, the facility failed to provide care and services to assist each resident in attaining or maintaining the highest physical well being possible for three (3) of thirty-seven (37) Stage II sample residents. Resident #55 expressed experiencing pain in his leg that kept him awake at night, and he had an order for [REDACTED].#62 did not eat for three (3) days, and staff failed to assess for possible causes and failed to notify the physician, although the resident did not have a known terminal illness; the resident died twenty-four (24) hours after the physician was notified. Resident #153 was not appropriately assessed for fall risk and sustained two (2) falls. These actions resulted in actual harm to Resident #55 and #62. Resident identifiers: Residents #55, #62, and #153. Facility census: 97. Findings include: a) Resident #55 In an interview conducted at 3:00 p.m. on [DATE], Resident #55 stated he had pain in his left leg and that it often kept him awake at night. At that time, the resident was observed rubbing his left thigh. The resident's medical record, when reviewed on [DATE], contained a current physician's orders [REDACTED]. Based on this order, facility staff should have been aware of the possibility of leg pain and should have provided ongoing assessments for this resident's specific pain. Review of the care plan, at the same time, revealed no care plan or other mention of leg pain. In an interview at 10:45 a.m. on [DATE], a registered nurse (RN - Employee #136) revealed she had no knowledge of the resident experiencing left leg pain. Employee #136 reviewed the resident's pain scores (pain assessments) for [DATE] and reported there was no documentation of pain thus far in April. She confirmed that the pain score record did not specifically indicate assessment of left leg pain. Employee #136 then visited the resident in his room. At 11:00 a.m. on [DATE], the RN reported the resident stated to her that he has left leg pain at night and that the leg pain kept him awake at night. The resident's care plan was again reviewed, this time with Employee #136. At 5:30 p.m. on [DATE], Employee #136 confirmed the facility was not aware the resident was having pain and confirmed that ongoing assessments for left leg pain had not been occurring for this resident. Employee #136 stated she would assess the resident and implement appropriate interventions. The following morning, another interview was conducted with the resident, at 9:00 a.m. on [DATE]. He stated he had been given pain medication for his leg pain last night and that it had really helped. He stated, I slept like a log. At the time of the survey, the facility had not assessed the resident's left leg pain and had not developed and implemented a care plan to ensure the resident was as free as possible of pain. b) Resident #62 Closed record review revealed Resident #62 was admitted on [DATE] for rehabilitation related to a fractured left hip for which she had undergone internal fixation at an area hospital on [DATE]. She had been in an assisted living facility at the time of the fall and was 100-years old. The resident's discharge summary from the hospital, in the area of condition on discharge, stated she was stable. Additional medical [DIAGNOSES REDACTED]. The resident / responsible party's goal at the time of admission, according to the social work assessment of [DATE], was for the resident to be able to return to the assisted living facility where she resided prior to the fall. At the time of admission, the resident's diet was noted to be regular mechanical soft. Shortly after admission, the resident was noted to be having some difficulty with swallowing. A speech evaluation was conducted on [DATE], and the resident's diet was changed to pureed with honey-like liquids. An interdisciplinary progress note, dated [DATE], stated that resident was in thirty (30) day window for the minimum data set assessment (MDS) and she continues to work with all therapy services. She continues to show progress. The medical record contained a Living Will document completed by the resident on [DATE], stating she desired to receive no life-prolonging interventions should she be diagnosed by two (2) physicians to have a terminal condition and/or to be in a vegetative state. She had included no limitations or special directives on this declaration. Review of the resident's physician orders [REDACTED]. party on [DATE], stated the resident was not to be resuscitated in Section A. In Section B, Limited Additional Interventions were requested, which direct staff to use medical treatment, IV fluids and cardiac monitoring as needed. Transfer to hospital if indicated. Avoid intensive care. In Section C, antibiotics were requested, and in Section D, no feeding tube was requested, although IV fluids for a defined trial period were also requested. Nursing notes from the time of admission described the resident as mostly resting in bed, meds taken crushed, and voicing no complaints. Family was noted to be visiting frequently. A nursing note, on [DATE] at 7:00 p.m., stated, Resting in bed. PO (by mouth) meds taken crushed (sic) without difficulty. No complaints noted. VSS (vital signs and symptoms) per flow sheet. Foley cath patent draining yellow urine. ADL's (activities of daily living) per staff. Call bell in reach. At 9:20 a.m. on [DATE], a nursing note stated, This nurse called to notify MD that resident has refused to eat for 3 days and that this nurse held am (morning) meds (medications) due to swallowing difficulty. At 1:00 p.m. on [DATE], an addition nursing note stated the family was in to visit and explained to MPOA (medical power of attorney representative ) that resident has refused to eat for 3 days and that nurse held morning meds. The resident had not eaten for three (3) days before staff notified the physician. There was no noted response from the physician after he was notified of the resident's failure to eat for three (3) days. Although documentation stated that family was made aware and was with the resident frequently, there was no evidence that, when made aware of this failure to eat, the resident's physician or facility personnel met with the family to discuss their desire to attempt to [DIAGNOSES REDACTED]. There was no discussion about obtaining lab work or other minimally invasive diagnostic tests to ascertain why this resident - with no known terminal diagnosis - was not eating. There was no discussion related to implementation of IV fluids for a trial period, as requested on the resident's POST form. The resident died at the facility within twenty-four (24) hours of this physician's notification of her failure to eat for three (3) days. c) Resident #153 The medical record of Resident #153, when reviewed on [DATE], disclosed this [AGE] year old resident had been admitted to the facility on [DATE]. The resident's medical [DIAGNOSES REDACTED]. Further review of the record revealed a history and physical completed at the time of her last hospitalization following admission, which stated: Her dementia seems to be progressing rather quickly and she is confused to place and time. Following admission to the facility, documentation on a social work assessment and history form stated the resident was alert and oriented to person with short and long term memory impairment. An admission nursing note, dated [DATE] at 2:00 p.m., stated, Alert to self and to familiar people. Confused to time and place. A nursing note, on [DATE] at 5:00 a.m., stated, Very forgetful, and at 2:45 p.m. on [DATE], a facility nurse documented in a nursing note, Forgetful of things you have just explained to her. The resident's care plan was reviewed, and staff had recognized, on [DATE], that the resident was at risk for falls due to cognitive impairment, adjustment to new environment, use of [MEDICAL CONDITION] medications, unsteady gait. Interventions to prevent falls included checking on resident frequently, providing assist to transfer and ambulate as needed, and reinforce need to call for assistance. On [DATE] at 9:00 a.m., a nursing note described finding the resident sitting on her buttocks in front of the toilet. The resident was assessed and determined to have no injuries. The resident also attempted to leave the building on two (2) occasions on this day, at 10:20 a.m. and again at 3:30 p.m., and a nursing note stated, Resident alert, confused to time and place. At 4:30 p.m. on [DATE], a nursing note stated, CNA (certified nursing assistant) took resident to bathroom and instructed to ring when done, resident got up from toilet on own - roommate stated res.(resident) walked to w/c (wheelchair) and fell to floor on back. The resident was transferred by emergency medical services to a local hospital emergency room for evaluation and returned to the facility at 8:35 p.m. on [DATE] with an order for [REDACTED].>The director of nurses (DON) and assistant director of nurses (ADON) were interviewed related to these findings at 10:00 a.m. on [DATE]. Following review of the resident's medical record and statements related to cognitive status as described above, the DON and ADON confirmed the care plan interventions for this resident (to call for assistance) and instructions by a nursing assistant (to call for assistance when done toileting) were not appropriate for this cognitively impaired resident. The resident did not have the ability to comprehend the instructions to call for assistance.",2015-11-01
9405,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,315,D,0,1,85AT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed, for one (1) of thirty-seven (37) Stage II sample residents, to assure timely and appropriate assessment for a resident who was continent of urine when admitted to the facility and who became totally incontinent within the four (4) months following admission, in an effort to determine the possible cause and to address the incontinence to the extent possible. Resident identifier: #153. Facility census: 97. Findings include: a) Resident #153 The medical record for Resident #153, when reviewed on 04/07/10, disclosed the resident was admitted to the facility on [DATE]. According to the Nursing Admission Evaluation completed on 11/23/09, as well as the Bladder Pattering and Analysis Worksheet completed on 11/24/09, the resident was continent of bladder function. An ADL (activity of daily living) Worksheet, completed during the month of January 2010, continued to note the resident as being continent of bladder function. ADL Worksheets for the months of February, March, and April 2010 disclosed the resident had declined in urinary continence to the current status of totally incontinent. The resident's current plan of care, when reviewed on 04/07/10, noted a focus area for this resident as: Occasional urinary incontinence related to hypertonicity bladder, physical limitations. This focus area was initiated on 12/08/09, and included interventions such as using absorbant products and adult briefs and providing incontinence care as needed. The care plan had been reviewed on 03/01/10, but no changes had been implemented to reflect the decreasing urinary continence as described on the ADL Worksheets for the period of time after mid-February 2010 to the present April 2010, when the resident was described as being totally incontinent of urine. A licensed practical nurse (LPN) assigned to the care of this resident on 04/08/10 (Employee #119), when question as to the urinary continence of this resident, stated the resident was almost totally incontinent and would only occasionally ask to go to the bathroom. These findings were bought to the attention of the director of nurses (DON) and assistant director of nurses (ADON) on 04/08/10 at 10:00 a.m., and they could provide no evidence that the facility had recognized the resident's decline in urinary continence, assessed for cause, and/or implemented interventions to assist the resident to regain as much normal bladder function as possible.",2015-11-01
9406,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,319,D,0,1,85AT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed, for one (1) of thirty (30) Stage II sample residents, to accurately assess the resident's increasing emotional distress / behaviors following a [DIAGNOSES REDACTED]. Resident identifier: #162. Facility census: 97. Findings include: a) Resident #162 When reviewed on [DATE], the closed medical record of Resident #162 disclosed she was 92-years old when admitted to the facility on [DATE] from a local acute care hospital with an admission [DIAGNOSES REDACTED]. The document Medical History / Physical Examination, completed by the resident's attending physician at the time of admission, stated the resident was recently diagnosed with [REDACTED]. Review of the resident's admission minimum data set assessment (MDS), dated as completed on [DATE], disclosed in the areas of Cognitive Patterns, Section B, the resident had long and short term memory problems but was able to recall the current season, staff names and faces, and that she was in a nursing home. In the area of emotional issues, Section E, the resident was described as experiencing [MEDICAL CONDITION] and repetitive physical movements. The document also stated that, although the indicators were present, they were easily altered. The next MDS, a Medicare 14-day assessment dated as completed on [DATE], described the resident as continuing to experience [MEDICAL CONDITION], having a sad / pained / worried / facial expression, and continuing to exhibit repetitive physical movements. Additionally, the resident had become physically abusive, resisted care, and indicators of [MEDICAL CONDITION] had surfaced. A social services note, dated [DATE], stated the resident had a decline in condition and was more confused, more restless especially at night, resisting care, and hitting at staff sometimes. The resident's care plan was reviewed. Staff had assessed the resident as having altered nutritional status related to terminal diagnosis, potential for pain related to [MEDICAL CONDITION], and other physical symptoms of the terminal diagnosis. However, there was no evidence in this care plan that staff had recognized the resident had experienced an increase in emotional distress / behaviors and restlessness in the fourteen (14) days following admission, nor was the resident assessed for possible unmet psychosocial needs associated recent being informed of a terminal [DIAGNOSES REDACTED]. The resident died at the facility on [DATE]. In an interview on [DATE] at 10:00 a.m., the director of nurses (DON) and assistant director of nurses (ADON) could provide no further evidence that the resident's documented and increasing emotional distress / behaviors had been assessed for the possibility of unmet psychosocial needs and developed interventions to assist the resident emotionally during the dying process.",2015-11-01
9407,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,325,D,0,1,85AT11,"Based on record review and staff interview, the facility failed to administer nutritional supplements as care planned and/or ordered for two (2) of thirty-seven (37) Stage II sample residents meant to optimize each resident's nutritional status. Resident identifiers: #111 and #94. Facility census: 97. Findings include: a) Resident #111 A review of the medical record revealed Resident #111 had a significant weight loss in November 2009. His care plan interventions included monitoring the percentage consumed of snacks / nutritional supplements, but there was no evidence on either the treatment sheet or the activities of daily living (ADL) worksheet for April 2010 that he received and/or consumed snacks / supplements as planned. b) Resident #94 A review of the medical record revealed Resident #94 was a debilitated hospice resident who weighed 70# and had a Stage II pressure ulcer on her coccyx. The progress notes stated she was declining in all areas. According to her medical record, snacks and/or nutritional supplements were care planned and/or ordered, but there was no evidence to reflect she received and/or consumed them. The area on the ADL worksheet, where staff was to document the acceptance of evening snacks for April 2010, was incomplete, with only three (3) of seven (7) days marked. A review of the resident's treatment sheet found evidence of her having received and/or refused her nutritional supplement on thirteen (13) of twenty-one (21) occasions when it was offered. c) During an interview with a nursing assistant (Employee #46) at 9:10 a.m. on 04/08/10, she verified these were the two (2) locations staff was to record whether a resident had and/or consumed snacks and/or supplements - the ADL worksheet and the treatment sheet. She stated the nursing assistants were to document the percentage of intake on the ADL worksheet. These findings were shared with the director of nurses (DON) at 9:30 a.m. on 04/08/10. After she review the resident's record, she stated she would take care of the problem.",2015-11-01
9408,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,364,F,0,1,85AT11,"Based on confidential resident interviews, taste testing, menu review, observation, temperature measurement of test trays, and staff interview, the facility failed to assure foods were palatable and at the proper temperatures upon receipt by the residents. Additionally, the facility failed to assure menus were followed relative to planned foods, alternate foods, and use of garnishes. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 97. Findings include: a) Confidential Resident Interviews 1. Resident A On 03/29/10 at 3:29 p.m., this resident stated No when asked if the food tasted good and looked appetizing. 2. Resident B On 03/29/10 at 3:55 p.m., this resident stated No when asked if the food tasted good and looked appetizing. The resident also stated a sandwich was requested regularly because of the taste of the food. 3. Resident C On 03/29/10 at 3:13 p.m., this resident stated No when asked if the food tasted good and looked appetizing. The resident also stated, .wish they had a good cook. 4. Resident D On 03/30/10 at 10:00 a.m., this resident stated, .the milk was warm most of the time. On 03/29/10 at 3:30 p.m., this resident stated the food was often cold and the milk was always warm. 5. Resident E On 03/29/10 at 3:45 p.m., this resident said, The food is not good. You can get something else, but it's not good either. 6. Resident F During the afternoon of 03/31/10, this resident said, The food tastes bad, looks bad, some cooked too much, some not enough. 7. Resident G On 03/29/10 at 3:30 p.m., this resident stated the cold foods were always too warm. 8. Resident H On 04/05/10 at 2:36 p.m., this resident stated the food was not good and needed more seasoning. -- b) During the noon meal on 04/07/10, the green beans were tasted and did not appear to have been seasoned. Employee #62, who prepared the green beans, stated she had seasoned the green beans with garlic powder. No such flavoring was detectable upon taste testing. This was confirmed by the dietary manager (DM) at 12:40 p.m. on 04/07/10. -- c) Temperatures of foods on test trays were measured at 1:05 p.m. on 04/07/10, just after the last resident was served. The cold foods were too warm. Cucumbers in ranch dressing were 56 degrees Fahrenheit (F), a small bowl of pudding was 52 degrees F, and tomato juice was 51 degrees F. These food temperatures were measured with the DM, who confirmed the cold foods were not at palatable temperatures. -- d) The menu was not followed for the noon meal on 04/07/10: 1. Residents requiring pureed diets were supposed to be provided pureed cucumbers in Ranch dressing, but they were provided tomato juice instead. 2. The menu called for garnishes for all diet types, but none were provided. 3. Specific alternates were indicated on the menu but were not prepared. Interview with the DM, at 12:40 p.m. on 04/07/10, revealed the facility had never prepared the alternates and had been cutting them off the menus when they were posted.",2015-11-01
9409,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,371,F,0,1,85AT11,"Based on observations and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices had the potential to affect all facility residents who received nourishment from the dietary department. Facility census: 97. Findings include: a) On 04/07/10 at 11:55 a.m., observation revealed the rinse temperature of the dishwasher was 198 degrees Fahrenheit (F). According to the 2005 Food Code, the rinse temperature should not exceed a maximum of 194 degrees F., to assure proper cleaning and sanitization. This situation was brought to the attention of the dietary manager (DM) at the time of observation. The DM stated she was unaware that rinse temperatures greater than 194 degrees F were ineffective in sanitizing food service items. Additionally observations at the same time revealed a large coating of dusty debris on the walls around the dishwasher, on top of the dishwasher, and on the ceiling vent above the dishwasher. b) During observation of meal preparation and meal tray preparation at the noon meal on 04/07/10, steam table pans were observed stacked inside each other prior to air drying. Trapped moisture was observed inside each one, creating a medium for bacteria growth. Additionally, these pans, which were ready for use, contained debris which could be scraped off with a fingernail. Plate covers were stacked inside of each other prior to air drying. They also contained some type of white loose debris. c) At 11:25 a.m. on 04/07/10, a pan of cucumber salad made with Ranch dressing was observed at the serving area, ready for service. The temperature of the product was measured. It was being held for service at 50 degrees F. The temperature of pureed green beans, being held for service on the steam table, was measured at the same time. They were 120 degrees F. d) At 12:15 p.m. on 04/07/10, the tray line (with rollers) contained large amounts of greasy, dusty debris on the rollers, as well as the other surfaces. e) At 12:25 p.m. on 04/07/10, during the loading of meal trays on the food carts. Large amounts of debris, including crumbs, paper, and dried food, were observed inside the food carts. Upon inquiry, the DM stated the inside of the food carts should have been cleaned during the time the dishes were washed.",2015-11-01
9410,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,387,D,0,1,85AT12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the attending physician, for one (1) of thirteen (13) residents reviewed, completed visits to the resident every thirty (30) days for the first ninety (90) days following admission as required. Resident identifier: #68. Facility census: 105. Findings include: a) Resident #68 When reviewed on 06/15/10, the medical record for Resident #68 disclosed the resident had been admitted to the facility on [DATE]. Further review found no evidence the resident had been seen by her attending physician since that time. The facility's administrator, when interviewed on 06/15/10 at 3:15 p.m., could provide no evidence to reflect the resident had been seen by her attending physician since the time of his admission to the facility on [DATE].",2015-11-01
9411,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,431,E,0,1,85AT11,"Based on observation and staff interview, the facility failed, for one (1) of two (2) medication refrigerators, to ensure the internal temperature was maintained in a safe range of 36 to 46 degrees Fahrenheit (F). Facility census: 97. Findings include: a) At 9:23 a.m. on 04/05/10, Employee #104 observed the refrigerator and identified it was above the upper limit of the safe zone at 50 degrees F. The employee adjusted the temperature control to a colder temperature.",2015-11-01
9412,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,441,E,0,1,85AT11,"Based on observation and staff interview, the facility failed to assure the surfaces of the hand rails in the hallways on one (1) wing of the facility, and the surfaces in an employee bathroom, were maintained in such a manner that they could be adequately cleaned and disinfected to prevent the spread of infection. This had the potential to affect more than an isolated number of residents. Facility census: 97. Findings include: a) On 03/30/10 and throughout the survey, the following observations were made: 1. The bathroom located adjacent to the 300-400 nursing station, which was used by employees providing direct care to the residents on these halls, was observed by this surveyor to have cracked and missing caulking around the toilet and sink, and plastic baseboards were loose in several areas with gaps that exposed dirt and debris. 2. The handrails along the 300 hall did not have a sealed surface, as there were many chinks out of the rail surface down into the bare wood. These conditions make it impossible to thoroughly clean and sanitize these areas. During an interview with the infection control nurse (Employee #32) at 9:00 a.m. on 04/08/10, she accompanied this surveyor to the areas in question and acknowledged they were not clean and probably could not be cleaned / sanitized.",2015-11-01
9413,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,456,F,0,1,85AT11,"Based on observation and staff interview, the facility failed to assure essential equipment in the kitchen was in safe operating condition. The rinse temperature of the dishwasher was at a temperature which did not effectively sanitize food preparation and service items. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 97. Findings include: a) On 04/07/10 at 11:55 a.m., observation revealed the rinse temperature of the dish washer was 198 degrees Fahrenheit (F). According to the 2005 Food Code, the rinse temperature should not exceed a maximum of 194 degrees F, to assure proper cleaning and sanitization. This situation was brought to the attention of the dietary manager (DM), at the time of observation. The DM stated she was unaware that rinse temperatures greater than 194 degrees F were ineffective.",2015-11-01
9933,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-06-15,387,D,0,1,85AT12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure the attending physician, for one (1) of thirteen (13) residents reviewed, completed visits to the resident every thirty (30) days for the first ninety (90) days following admission as required. Resident identifier: #68. Facility census: 105. Findings include: a) Resident #68 When reviewed on 06/15/10, the medical record for Resident #68 disclosed the resident had been admitted to the facility on [DATE]. Further review found no evidence the resident had been seen by her attending physician since that time. The facility's administrator, when interviewed on 06/15/10 at 3:15 p.m., could provide no evidence to reflect the resident had been seen by her attending physician since the time of his admission to the facility on [DATE].",2015-08-01
10337,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2012-01-31,279,D,1,0,X6UI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview, staff interview, and family interview, the facility failed to develop an interim care plan upon admission related to anticoagulant use for one (1) of sixteen (16) sampled residents. This resident was known to be on anticoagulants, and was allowed to be shaved by facility staff with a disposable razor. The resident was nicked several times one day while being shaved, yet the care plan was still not developed until two (2) days later when the family requested the resident to be shaved only with an electric razor. Resident identifier. #79. Facility census: 105. Findings include: a) Resident #79 Resident #79 was admitted to the facility, on 01/16/12, with a history of [MEDICAL CONDITION] and embolism, history of old [MEDICAL CONDITION] infarction, and history of a stroke resulting in hemipalegia affecting his non-dominant side. Record review revealed his [DIAGNOSES REDACTED]. During an interview with this resident, on 01/31/12 in the early afternoon, he stated an employee had shaved him with a disposable razor on 01/29/12. The employee had nicked him several times on his face. Observation revealed four (4) small dried scabs on his face. During an interview with a family member, on 01/31/12 in the early afternoon, it was found the family had voiced a complaint to the facility earlier that day about his having been nicked while being shaved on 01/29/12. They requested that a family member come in to shave him on 02/02/12. The family would bring in an electric razor for the resident's use. In an interview, on 01/31/12 in the early afternoon, the director of nursing stated the facility had no policy prohibiting a resident who was on anticoagulant therapy from being shaved by staff with a disposable razor, as long as their PT/INR lab work was normal. However, those residents were not allowed to have disposable razors in their rooms for their own personal use. When asked, she said they had no policy prohibiting aides from trimming the nails of residents who were on anticoagulant therapy. Review of the resident's care plan revealed it was updated on 01/31/12 to include a new focus on anticoagulant therapy for [MEDICATION NAME], and being at risk for adverse effects. A new intervention included nursing staff were not to shave the resident, and the family would obtain an electric shaver for family members to use on him. Another new intervention was to report adverse effects such as blood in the urine or stool, bleeding of the gums or nose, and bruising. Other interventions included to administer (anticoagulant therapy) per physician orders, obtain labs as ordered and notify the physician, obtain vital signs as necessary. Review of the medical record found an abnormal PT blood level on 01/31/12 of 78.4, with the normal reference range being 9.1 - 11.5. The INR was also abnormally elevated at 8.1, with the normal reference range between 0.8 and 1.2. For conventional anticoagulation, the range is between 2.5 and 3.0. For intensive anticoagulation, the range is between 2.5 to 3.5. During interviews with nurses, Employees #12, #52, and #104, in the late afternoon on 01/31/12, they reported the aide (Employee #111) who shaved Resident #79 on 01/29/12, had over [AGE] years experience. They provided a copy of the patient information worksheet the aides used daily, and stated it was updated that day for the resident to not be shaved by staff, and the family would shave him with an electric razor. .",2015-05-01
10783,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-08-02,154,D,1,0,H4MU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, physician interview, and family interview, the facility failed to ensure the responsible party of one (1) of five (5) sampled residents, who lacked capacity to understand and make informed healthcare decisions, was informed in advance about a change in care that may affect the resident's well-being. The facility did not receive approval from Resident #72's health care surrogate (HCS) before discontinuing the resident's medication, labs and diagnostic tests, and weights. Facility census: 106. Findings include: a) Resident #72 Record review revealed Resident #72 was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident weighed 88 pounds (#) on admission, and his current weight on 08/02/11 was 98#. -- On 06/23/11, a physician's orders [REDACTED]. Resident refusal."" -- An interview with the social worker, on 08/02/11 at 11:35 a.m., revealed the social worker had no knowledge of the resident not receiving his medication, labs and diagnostic tests, and weights. She was not aware that the resident was refusing to take his medication and was refusing to be weighed. She also stated, ""I was unaware that the HCS was not returning the calls to the nursing staff about his (the resident's) refusal to take his medication and refusing to be weighed."" -- An interview with the director of nursing (DON), on 08/02/11 at 10:00 a.m., revealed the resident was refusing to take his medication and refusing to be weighed. She stated, ""The HCS was notified multiple times and did not return the calls."" She further stated, ""When a resident is refusing to take their medication and refusing to be weighed, it is my practice to have the physician discontinue the medication and weights."" -- An interview with the physician, on 08/02/11 at 2:00 p.m., revealed the physician was unaware that the resident's HCS was not informed of the medications and the weights discontinued. She stated, ""Put me through to the charge nurse, and I will get the ball rolling to change the HCS if necessary."" -- An interview with the resident's HCS, on 08/02/11 at 2:15 p.m., revealed she could not remember if she had returned a call to approve the discontinuation of the medications and weights. She reported she was unaware that she was responsible for making the decisions concerning the resident's medical needs. She stated, ""I now understand my responsibilities concerning (Resident #72's) health needs and want to remain his HCS."" .",2014-12-01
10784,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-08-02,250,D,1,0,H4MU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility did not provide medically-related social services to one (1) of five (5) sampled residents. Resident #72 lacked the capacity to understand and make informed healthcare decisions. The facility discontinued all of his medications, labs and diagnostic tests, and his weights without having approval from the resident's health care surrogate (HCS). Nursing staff attempted to notify the HCS before discontinuing the medication and weights, and the HCS did not respond to the telephone notifications. The nursing staff notified the physician, who gave orders to discontinue the medications and weights. The social services director, who was unaware of the resident's refusals and unaware that the HCS had failed to respond to notification attempts by the facility, did not ensure the resident had representation from an HCS who was acting in accordance with the resident's known wishes or, if these were not known, his best interests. Facility census: 106. Findings include: a) Resident #72 Record review revealed Resident #72 was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident weighed 88 pounds (#) on admission, and his current weight on 08/02/11 was 98#. -- On 06/23/11, a physician's orders [REDACTED]. Resident refusal."" -- An interview with the social worker, on 08/02/11 at 11:35 a.m., revealed the social worker had no knowledge of the resident not receiving his medication, labs and diagnostic tests, and weights. She was not aware that the resident was refusing to take his medication and was refusing to be weighed. She also stated, ""I was unaware that the HCS was not returning the calls to the nursing staff about his (the resident's) refusal to take his medication and refusing to be weighed."" -- A review of social service notes for June 2011 found no acknowledgement of awareness that the HCS was not responding to calls from the nursing staff. -- A review of the resident's initial care plan revealed the following: Focus: ""History of hoarding of medication in oral cavity and then saving them in drawer."" Goals: ""Provide safe environment daily through next review."" Interventions: ""Observe resident for hoarding meds in mouth. If hoarding in mount present, crush medications. If resident resists crushing meds, check oral cavity after administering."" - Focus: ""At risk for changes in mood r/t (related to) resident's desire to transfer facilities and lack of family contact at times."" Goals: ""Will maintain involvement with ADL (activities of daily living) performance and social activities."" Interventions: ""Assess for physical / environmental changes that may precipitate change in mood. Observe for and report any changes in mood. Offer choices to enhance sense of control. Provide emotional support/education to patient and/or family as needed. Validate feelings of loss."" -- An interview with the director of nursing (DON), on 08/02/11 at 10:00 a.m., revealed the resident was refusing to take his medication and refusing to be weighed. She stated, ""The HCS was notified multiple times and did not return the calls."" She further stated, ""When a resident is refusing to take their medication and refusing to be weighed, it is my practice to have the physician discontinue the medication and weights."" -- An interview with the physician, on 08/02/11 at 2:00 p.m., revealed the physician was unaware that the resident's HCS was not informed of the medications and the weights discontinued. She stated, ""Put me through to the charge nurse, and I will get the ball rolling to change the HCS if necessary."" -- An interview with the resident's HCS, on 08/02/11 at 2:15 p.m., revealed she could not remember if she had returned a call to approve the discontinuation of the medications and weights. She reported she was unaware that she was responsible for making the decisions concerning the resident's medical needs. She stated, ""I now understand my responsibilities concerning (Resident #72's) health needs and want to remain his HCS."" .",2014-12-01
10785,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-08-02,360,D,1,0,H4MU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide a nourishing diet that meets the daily nutritional and special dietary needs of one (1) of five (5) sampled residents. Record review revealed Resident #72 weighed 88 pounds (#) on admission and now weighed 98#. The resident's ideal body weight range was 145# to 165#, and the resident was not ordered an enhanced diet to promote weight gain. Resident identifier: #72. Facility census: 106. Findings include: a) Resident #72 Record review revealed Resident #72 was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident's weight fluctuated from 88.2 pounds (#) on admission to 102#. The resident's weight on 08/02/11 was 98#. An interview with the registered dietitian (RD - Employee #129), on 08/02/11 at 11:00 a.m., revealed the RD did not understand why the resident was not receiving enhanced foods related to his weight loss. She stated, ""He should have received the enhanced food with the diet orders on admission."" She stated, ""I will give the resident enhanced food on his diet."" An interview with the dietary manager (Employee #11), on the morning of 08/02/11, revealed the resident did not have an enhanced diet related to the amount of snacks in his room. The dietary manager reported the family brought in snacks, crackers, peanut butter, and candy and that was what he ate all of the time. She felt that, with the amount of snacks in the resident's room, he did not need an enhanced diet. A review of the resident's care plan on admission revealed the following: Focus: ""Potential for nutritional impairment r/t (related to) prior history of malnutrition and less than 50% of food consumed and history of GERD."" Goals: ""Will consume / tolerate 50% of meals and 75%-100% of fluids provided daily through next review."" Interventions: ""Encourage and assist as needed to consume mechanical soft diet. Administer [MEDICATION NAME] per MD orders. Resident pretends to be sleeping when tray is served or he is on phone and doesn't eat food while it is hot. When he pretends he is sleeping, he does not rouse when stimulated to open eyes and eat. Re-heat food as needed. Discontinue weights due to resident does not eat meals, but eats snacks family brings in. Resident consumes a lot of snack food that family brings, will overindulge to the point of vomiting at times. Encourage to sit upright with meals and afterward for 1 hour. Magic cup served with each meal on tray."" A review of the nutrition risk assessment on 04/09/10 (date of admission), the resident was assessed as weighing 88.2#. The resident was consuming all of the Ensure nutritional supplement. The resident's ideal body weight was listed as 145# to 165#. The resident was consuming 100% of his meals. A dietary note, dated 08/17/10, stated the resident's meal intake was 50% with all meals. The resident was receiving [MEDICATION NAME] (an appetite stimulant) and Ensure three (3) times a day with meals. His current weight 102.8#. On 05/01/11, the resident was receiving Ensure one (1) time a day related to refusing to drink the Ensure three (3) times a day. On 06/23/11, the physician discontinued all medications (except those ordered on a PRN (as needed) basis) and all weights related to the resident's refusal.",2014-12-01
10978,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-06-02,225,D,1,0,TI3G11,". Based on medical record review, staff interview, and a review of the facility's abuse policies and procedures, the facility failed to immediately report all allegations of neglect. This occurred for one (1) of eight (8) sampled residents. Resident identifier: #79. Facility census: 109. Findings include: a) Resident #79 Review of Resident #79's medical record revealed a nursing note, dated 05/28/11 at 1:30 p.m., detailing the reaction of the resident's daughter to finding the resident still in bed at lunch time. The daughter was quoted as stating, ""Why isn't she up; does she have to wait all day."" This constituted an allegation of neglect, based on the daughter's perception that care had not been provided to her mother. The daughter and her spouse then proceeded to give the resident a bed bath, changing her incontinence brief and stripping her bed without staff assistance. During an interview with the resident on 06/02/11 at 10:35 a.m., she stated, ""I told the aides I wanted to get up, and they said there wasn't enough help."" She did not remember saying she was sick and did not want to get up. She said she told her daughter when she came in to see the resident, and that was when her daughter talked to the staff. Review of the facility's policy titled ""Abuse, Neglect and Misappropriation of Patient Property Prevention"" found the following in the section titled ""Prevent, Procedures for Reporting Concerns, Incidents and Grievances"": ""The administrator designates a staff member as an abuse prevention coordinator to manage and evaluate the abuse prevention process. There is evidence in the center that guidelines and process to prohibit abuse, neglect, involuntary seclusion and misappropriation of property for patients are operational. The administrator is responsible for the investigating, reporting, and coordinating of the investigation process of any alleged or suspected abuse. The abuse prevention coordinator interacts with the survey team to explain the center's abuse, neglect and misappropriation of patient property prevention process. ""Centers can best support the detection an prevention of abuse, neglect and misappropriation of patient property by implementing a process that supports immediate reporting of suspected abuse, neglect, neglect and misappropriation. The process should be available to patients, family members, advocates and staff to report abuse, neglect and misappropriation of patient property in a manner that elicits immediate attention without fear of retribution. The abuse prevention coordinator should provided feedback to patients, family members and staff regarding any concerns or grievances that have been exposed."" During an interview at 2:00 p.m. on 06/01/11, the director of nursing (DON), after reviewing the nursing notes for this resident, said she did not understand why the incident should have been reported to the State survey agency. .",2014-10-01
10979,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-06-02,226,D,1,0,TI3G11,". Based on medical record review, staff interview, and a review of the facility's abuse policies and procedures, the facility failed to implement its policy for reporting all allegations of neglect. This occurred for one (1) of eight (8) sampled residents. Resident identifier: #79. Facility census: 109. Findings include: a) Resident #79 Review of Resident #79's medical record revealed a nursing note, dated 05/28/11 at 1:30 p.m., detailing the reaction of the resident's daughter to finding the resident still in bed at lunch time. The daughter was quoted as stating, ""Why isn't she up; does she have to wait all day."" This constituted an allegation of neglect, based on the daughter's perception that care had not been provided to her mother. The daughter and her spouse then proceeded to give the resident a bed bath, changing her incontinence brief and stripping her bed without staff assistance. During an interview with the resident on 06/02/11 at 10:35 a.m., she stated, ""I told the aides I wanted to get up, and they said there wasn't enough help."" She did not remember saying she was sick and did not want to get up. She said she told her daughter when she came in to see the resident, and that was when her daughter talked to the staff. Review of the facility's policy titled ""Abuse, Neglect and Misappropriation of Patient Property Prevention"" found the following in the section titled ""Prevent, Procedures for Reporting Concerns, Incidents and Grievances"": ""The administrator designates a staff member as an abuse prevention coordinator to manage and evaluate the abuse prevention process. There is evidence in the center that guidelines and process to prohibit abuse, neglect, involuntary seclusion and misappropriation of property for patients are operational. The administrator is responsible for the investigating, reporting, and coordinating of the investigation process of any alleged or suspected abuse. The abuse prevention coordinator interacts with the survey team to explain the center's abuse, neglect and misappropriation of patient property prevention process. ""Centers can best support the detection an prevention of abuse, neglect and misappropriation of patient property by implementing a process that supports immediate reporting of suspected abuse, neglect, neglect and misappropriation. The process should be available to patients, family members, advocates and staff to report abuse, neglect and misappropriation of patient property in a manner that elicits immediate attention without fear of retribution. The abuse prevention coordinator should provided feedback to patients, family members and staff regarding any concerns or grievances that have been exposed."" During an interview at 2:00 p.m. on 06/01/11, the director of nursing (DON), after reviewing the nursing notes for this resident, said she did not understand why the incident should have been reported to the State survey agency. .",2014-10-01
10980,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-06-02,323,D,1,0,TI3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on resident interview, medical record review, and staff interview, the facility failed to provide adequate supervision to prevent avoidable accidents for one (1) of eight (8) sampled residents. Resident #79, who was being changed by a nurse aide following an episode of incontinence, was instructed by the aide to roll over. The resident had left-sided hemiparesis as the result of a stroke as well as right sided weakness, and she was unable to use her left arm / hand to assist with bed mobility. The resident rolled out of the bed and fell to the floor, sustaining a hematoma to the left temple, resulting in evaluation and treatment at the local hospital's emergency department. Record review revealed a comprehensive minimum data set assessment (MDS) stating the resident required the assistance of two (2) or more persons with bed mobility. The occupational therapy weekly status summary stated she was dependent on staff for bed mobility. The physical therapy weekly status summary stated she required maximum assistance of two (2) with bed mobility. The care plan did not specify how many staff persons were to assist her with bed mobility, and the kardex used by the nurse aides stated she ""usually"" required the assistance of only one (1) staff person with bed mobility. There was no evidence that the facility provided instructions to the nurse aides to ensure the resident consistently received the amount of assistance she required to safely turn and reposition in bed, in view of her left-sided hemiparesis and right-sided weakness. Resident identifier: #79. Facility census: 109. Findings include: a) Resident #79 1. During a tour of the facility on 05/31/11 at 10:00 a.m., observation found Resident #79 in bed with bruising above and below her left eye. Review of Resident #79's medical record revealed this [AGE] year old female was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. This resident was alert and oriented and possessed the capacity to understand and make informed health care decisions. Review of her nursing notes revealed an entry, on 05/15/11 at 5:00 a.m., stating (quoted as written): ""this nurse called to resident's room. CNA (certified nursing assistant) reported to this nurse that res (resident) was on the floor. upon arrival to room, res noted to be laying on (L) ( left) side between the bed & dresser. bed noted to be in low position. res stated 'My brief was being changed & suddenly the bed wasn't there.' res c/o (complained of) of left knee & ankle pain. small red raised area noted to (L) forehead / temple. res states pain is an '8' on scale of 0 -10. incontinent care provided. res assisted onto back & covered for dignity."" When interviewed on 06/01/11 at 12:45 p.m., Resident #79 reported feeling bad because her therapy was not going well as she would like. When asked, she was able to recall having fallen out of her bed on the early morning of 05/15/11. Her account was consistent with the account recorded in the nursing notes for that date. The resident reported she fell to the right. She said she had a trapeze bar but did not use it when she was being changed following incontinence episodes. -- 2. The accident / incident report, dated 05/15/11 at 5:00 a.m., stated (quoted as typed), ""during incontinent care resident rolled out of bed onto the floor landing on left side. resident is complaining of pain in the left knee and ankle. also has a knot of left forehead."" The emergency record dated 05/15/11 stated under the heading ""Instruction"": ""Discharge: Head Injury, NOS (not otherwise specified), Contusion. Follow up: Follow up with Primary Care Physician in 2-3 days. Special: Nursing home should do neurologic checks throughout the day."" -- 3. Review of Resident #79's comprehensive admission minimum data set (MDS), with an assessment reference date of 04/22/11, found in Section G the assessor encoded the resident as requiring the extensive physical assistance of two (2) or more persons with bed mobility. -- 4. Review of an occupational therapy evaluation form, signed by the occupational therapist on 04/18/11, found the following under the heading ""Summary and Assessment"": ""Res. (resident) evaluated this date for skilled OT (occupational therapy) (symbol for 'secondary') to Res & family wanting Res to return home. ... Res ... demonstrates decline /c ADL's, Fxnal (functional) mobility, (L) hand contracture at wrist PIP (proximal interphalangeal) & DIP (distal interphalangeal) jts (joints), & (L) UE (upper extremity) swelling. ..."" Review of an occupational therapy summary form, signed by the occupational therapist on 05/26/11, found the following under the heading ""Weekly Status"" related to the resident's ability to perform bed mobility: 04/18/11 - Initial Status - Dep (dependent) 04/26/11 - Dep 05/02/11 - Dep 05/10/11 - Dep 05/16/11 - Dep - Review of a physical therapy evaluation form, signed by a physical therapist on 04/16/11, found the following under the heading ""Summary and Assessment"": ""Resident presents /c (with) (L) (left) sided hemiparesis. She had CVA in 2008. ... She has had a recent decline in function and would like to resume PT (physical therapy) in attempts to improve her (R) (right) sided strength so she can assist more /c transfers and (arrow pointing) her ability for toileting / dignity."" Review of a physical therapy summary form, signed by the physical therapist on 05/19/11, found the following under the heading ""Weekly Status"" related to the resident's ability to roll / turn (bed mobility): 04/16/11 - Initial Status - Max 2 04/23/11 - NT 04/30/11 - Max 2 05/07/11 - Max 2 05/14/11 - Max - In an interview on 06/01/11 at 4:30 p.m., the rehabilitation program supervisor (Employee #80) explained that ""Max 2"" meant ""maximum assist with two (2)."" -- 5. Review of the care plan, with the director of nursing (DON) at 3:30 p.m. on 06/01/11, revealed the following: - A problem statement on page 3 of 14 (quoted as typed): ""ADL Self care deficit as evidence by need for assist with ADLs related to left [DIAGNOSES REDACTED] (Created on: 4/15/2011)."" The goal associated with this problem statement was: ""Will maintain existing ADL self performance while working with therapy services to limit further decline daily thru next review (Date initiated: 4/25/2011)."" Interventions to assist the resident in achieving this goal included: ""... Encourage and/or assist to reposition frequently (Created on 4/15/2011). ... Uses Trapeze to help assist with mobility (Created on 5/17/2011). ..."" The care plan did not specify the amount of staff assistance Resident #79 required for performing bed mobility, in view of her inability to turn on her right side independently due to left-sided hemiparesis and right-sided weakness. - - A problem statement on page 5 of 14 (quoted as typed): ""Falls due to impaired balance / poor coordination, hemiparesis related to late effects of CVA (cerebrovascular accident) (Created on 4/15/2011)."" The goal associated with this problem statement was: ""Minimize risk of injury related to falls daily through next review (Date initiated: 5/15/2011)."" Interventions to assist the resident in achieving this goal were: ""Have commonly used articles within easy reach (Date initiated: 4/15/2011). PT as ordered (Dated initiated 4/15/2011). Bariatric mattress (Dated initiated: 5/15/2011)."" The care plan, again, did not specify the amount of staff assistance Resident #79 required for performing bed mobility, especially in view of the fact that the fall occurred while the resident was being turned / repositioned to facilitate incontinence care. Additionally, the only new intervention added after the fall was to provide the resident with a bariatric mattress. -- 6. Review of the kardex found on the computer kiosk, with a nursing assistant who was providing care for the resident on 06/02/11 at 3:00 p.m. (Employee #45), found the following under the heading ""ADL's / Restorative Care"" (quoted as typed): ""*ADL Assist - Usually 1 person with total assist (encourage resident to participate as able) (FYI)"" Employee #45 reported she would sometimes reposition the resident in bed without assistance, and sometimes the resident required two (2) staff, but it just depended on how close to the edge of the bed the resident was. -- 7. Review of documentation entered by nursing assistants in the task list, regarding the amount of assistance provided to Resident #79 for bed mobility for the period 05/03/11 through 05/14/11, found the resident was repositioned by two (2) staff members on twenty-seven (27) occasions and by only one (1) staff member on eleven (11) occasions. This information was reviewed with the MDS nurse and a nurse manager (Employees #93 and #54) on the mid-afternoon of 06/01/11. -- 8. On 06/01/11 at 4:15 p.m., the administrator provide a copy of the nurse aide job description (dated 08/02 and revised 02/08) and highlighted a sentence under the heading ""Safety and Sanitation"" that stated: ""Observes safety needs of patients as indicated in care plan."" He stated Resident #79 was to receive the assistance of one (1) staff person for bed mobility. Further review of the section titled ""Personal Nursing Care Responsibilities"" found the nurse aide's responsibilities included: ""Assists resident with lifting, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc., in keeping with specific resident safety needs."" Under the heading ""Special Nursing Care Responsibilities"", one (1) of the responsibilities was: ""Turns bedfast residents as instructed."" -- 9. Because the care plan did not instruct staff in the amount of assistance to be provided for bed mobility, and because the kardex stated the resident ""usually"" required only the assistance on one (1) person for bed mobility, there was no evidence that the facility provided instructions to the nurse aides to ensure the resident consistently received the amount of assistance she required to safely turn and reposition in bed, in view of her left-sided hemiparesis and right-sided weakness. It was determined that the resident's fall from bed on the morning of 05/15/11 was an avoidable accident. -- During an interview on the early afternoon of 06/02/11, the DON confirmed the resident was provided a bariatric bed after the fall, so she would have more room to turn. --- Part II - Based on observations and staff interview, the facility failed to provide a safe environment for residents as items not in use (such as wheelchairs, mechanical lifts, medication carts, stationary isolation cabinets, and linen carts) were stored in the hallways. This has the potential to affect residents of the facility who are independent with locomotion. Facility census: 109. Findings include: a) During a tour conducted on 05/31/11 at 10:55 a.m., the 100-200 hallways had the following equipment staged but not in use in the left side of the hallway: - Six (6) wheelchairs; - One (1) linen cart; - Two (2) white cans; - Three (3) portable vital sign machines; - One (1) cleaning cart; and - Two (2) stationary isolation carts on the left side of the hallway. Additionally, one (1) stationary isolation carts was found on the right side of the hallway. The isolation carts were observed sitting directly on the floor. They were not mobile, as they had no wheels. -- b) As the tour of the facility continued, observation found the following items staged but not in use on the 300-400 hallways: - Two (2) clean linen carts; - One (1) portable blood pressure monitor; - Three (3) stationary isolation carts; - One (1) dirty linen cart; and - One (1) wheelchair. Also observed in the hallway was a mechanical lift (staged but not in use) located just outside of an alcove where three (3) other lifts were stored. -- c) On 06/02/11 at 9:30 a.m., the administrator (Employee #133) and the maintenance director (Employee #92) were asked about the equipment staged but not in use in the 100-200 hallways. At that time, observation found: - One (1) treatment cart; - One (1) mechanical lift; - Six (6) wheelchairs; - One (1) white plastic can; - One (1) linen cart; and - One (1) geri-chair. The administrator said the building was thirty (30) years old. He also said the wheelchairs were to be collapsed and stored against the wall or in the resident's room, if space allowed. The maintenance director placed the mechanical lift in a storage alcove, and the administrator collapsed one (1) wheelchair and placed it against the wall. The other wheelchairs remained in the hallway. -- d) Further observation, on 06/02/11 at 10:55 a.m., found the same equipment in the 100-200 hallway was the same except for one (1) wheelchair (which was collapsed and stored against the wall) and the mechanical lift (which had been moved into the alcove). -- e) The administrator did not provide a policy and procedure for equipment storage, in response to the survey team's request, prior to the team's exit from the facility on the afternoon of 06/02/11. .",2014-10-01
10981,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-06-02,371,E,1,0,TI3G11,". Based on resident interview, observation, and staff interview, the facility failed to ensure dry foods were stored under sanitary conditions to prevent contamination by pests. This has the potential to affect all residents receiving food from the dietary department. Facility census: 109. Findings include: a) Residents #88 and #22 During the initial tour of the facility on 05/31/11 beginning at 9:45 a.m., two residents (#88 and #22 ) reported they did not like the Rice Crispies that was put into bowls, because they saw ""bugs"" crawling in their breakfast cereal earlier that morning. During breakfast on 06/02/11, these residents were interviewed again, and Resident #66 had two (2) bowls of Rice Crispies sitting on his overbed table. These bowls were observed, and there were no insects in the cereal at that time. In the company of the facility's dietitian (Employee #135) on 06/02/11 at 8:55 a.m., a box of bulk Rice Crispies was observed in the dry goods storage area adjacent to the kitchen. The opened box contained one (1) bag of cereal that was not opened. On the outside of the bag was a dead winged insect measuring approximately one eighth (1/8) inch in length. The insect was subsequently shown to Residents #88 and #22, and they reported this insect was similar in appearance to the ones they found in their cereal earlier in the week. The insect was then taken to the administrator for observation. An interview with the dietary manager (Employee#10), on 06/02/11 at 11:00 a.m., found the facility had a problem with inspects in the cereal about a year ago. She reported there were no other insects found in the food in dietary on 06/02/11. She said one (1) of the dietary employees prepared six (6) bowls of cereal earlier in the week, but she did not acknowledge whether there were any insects in them. .",2014-10-01
10982,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-06-02,312,D,1,0,TI3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on facility record review, family interview, resident interview, observation, and staff interview, the facility failed to provide assistance with oral hygiene to one (1) of eight (8) sampled residents who was not independent in performing this activity. Resident identifier: #109. Facility census: 109. Findings include: a) Resident 109# Review of Resident #109's medical record revealed this [AGE] year old female resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her minimum data set assessment, with an assessment reference date of 05/11/11, indicated she had no cognitive impairment and she required the extensive assistance of staff for personal hygiene including brushing teeth. A care plan, initiated by the resident assessment coordinator (Employee #102) on 05/03/11, contained the following intervention: ""Assist with daily hygiene, grooming, dressing, oral care and eating as needed."" In an interview on 06/01/2011 at 9:30 a.m., Resident #109's family member said she had complained that her mouth was sore approximately ten (10) days after her admission to the facility. The family member inspected the resident's mouth and stated, ""It made me sick."" Mouth care products brought to the facility by the family on admission had not been used. On 06/01/11 at 4:30 p.m., an interview with Resident #109 revealed no oral or denture care had been provided. When asked if her dentures had been cleaned today, she replied, ""No."" When asked how many times, over the last five (5) days, staffed cleaned her dentures, she stated ""twice"". Her dentures were observed to contain food particles. During this interview, the resident repeatedly put her hand over her mouth. On 06/02/11 at 10:00 a.m., the director of nursing (DON - Employee #18) was asked for a copy of the activity of daily living (ADL) documentation for Resident #109, on which direct care staff were to record the provision of ADL assistance given to the resident. The ADL sheet did not contain any documentation of oral care. The DON said mouth care was not recorded and was considered part of the ADLs that were to be completed by direct care staff. .",2014-10-01
10983,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-06-02,242,B,1,0,TI3G11,". Based on confidential resident interviews, review of the facility's planned cycle menus, observation, and staff interview, the facility failed to afford residents the right to choose a meal plan containing a variety of food items. The planned cycle menus for Weeks #1 and #3 were repetitious of entrees comprised of meat / tomato products and fish with breading and tartar sauce, respectively. Facility census: 109. Findings include: a) In confidential interviews, residents complained of the food items on the menu being ""all the same"", with little variety at times. Observation of the facility's current 4-week cycle menu found, in Week #1, three (3) consecutive days when the entrees included meat and tomato products in combination. On Tuesday 05/31/11 at the noon meal, the entree was Coney Chili on Bun; this was tasted by two (2) surveyors. On Wednesday 06/01/11 at the evening meal, the entree was Sloppy Joe on Bun; this was also sampled by the surveyors and was found to be very similar in taste, appearance, and texture to the Coney Chili offered the previous day at lunch. A review of the cycle menu and the recipes for both Coney Chili and Sloppy Joes, with the dietary manager (Employee #10) on the evening of 06/01/11, found the contents, flavor, and appearance of both items were similar. Further review of the menu with the dietary manager found a third meat / tomato product entree was to be served at the noon meal on Wednesday 06/02/11 - BBQ Pork on Bun. All three (3) of these items were found on the planned cycle menu for Week #1. Further review of the same cycle menu found, for Week #3, the following three (3) entrees that would be similar in content, taste, and appearance: - Sunday evening meal - Fish Sandwich with Tartar Sauce - Tuesday evening meal - Breaded Fish with Tartar Sauce - Wednesday noon meal - Crumb Topped Fish with Tartar Sauce The dietary manager acknowledged the menu did appear to include entrees that were similar to each other, and she agreed the taste and appearance of these entrees would be similar in nature. .",2014-10-01
10984,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-06-02,279,D,1,0,TI3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, medical record review, and staff interview, the facility failed to develop a care plan based on a comprehensive assessment to prevent avoidable accidents for one (1) of eight (8) sampled residents. Resident #79, who was being changed by a nurse aide following an episode of incontinence, was instructed by the aide to roll over. The resident had left-sided [MEDICAL CONDITION] as the result of a stroke as well as right sided weakness, and she was unable to use her left arm / hand to assist with bed mobility. The resident rolled out of the bed and fell to the floor, sustaining a hematoma to the left temple, resulting in evaluation and treatment at the local hospital's emergency department. Record review revealed a comprehensive minimum data set assessment (MDS) stating the resident required the assistance of two (2) or more persons with bed mobility. The occupational therapy weekly status summary stated she was dependent on staff for bed mobility. The physical therapy weekly status summary stated she required maximum assistance of two (2) with bed mobility. The care plan did not specify how many staff persons were to assist her with bed mobility, and the kardex used by the nurse aides stated she ""usually"" required the assistance of only one (1) staff person with bed mobility. There was no evidence that the facility provided instructions to the nurse aides to ensure the resident consistently received the amount of assistance she required to safely turn and reposition in bed, in view of her left-sided [MEDICAL CONDITION] and right-sided weakness. Resident identifier: #79. Facility census: 109. Findings include: a) Resident #79 1. During a tour of the facility on 05/31/11 at 10:00 a.m., observation found Resident #79 in bed with bruising above and below her left eye. Review of Resident #79's medical record revealed this [AGE] year old female was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. This resident was alert and oriented and possessed the capacity to understand and make informed health care decisions. Review of her nursing notes revealed an entry, on 05/15/11 at 5:00 a.m., stating (quoted as written): ""this nurse called to resident's room. CNA (certified nursing assistant) reported to this nurse that res (resident) was on the floor. upon arrival to room, res noted to be laying on (L) ( left) side between the bed & dresser. bed noted to be in low position. res stated 'My brief was being changed & suddenly the bed wasn't there.' res c/o (complained of) of left knee & ankle pain. small red raised area noted to (L) forehead / temple. res states pain is an '8' on scale of 0 -10. incontinent care provided. res assisted onto back & covered for dignity."" When interviewed on 06/01/11 at 12:45 p.m., Resident #79 reported feeling bad because her therapy was not going well as she would like. When asked, she was able to recall having fallen out of her bed on the early morning of 05/15/11. Her account was consistent with the account recorded in the nursing notes for that date. The resident reported she fell to the right. She said she had a trapeze bar but did not use it when she was being changed following incontinence episodes. -- 2. The accident / incident report, dated 05/15/11 at 5:00 a.m., stated (quoted as typed), ""during incontinent care resident rolled out of bed onto the floor landing on left side. resident is complaining of pain in the left knee and ankle. also has a knot of left forehead."" The emergency record dated 05/15/11 stated under the heading ""Instruction"": ""Discharge: Head Injury, NOS (not otherwise specified), Contusion. Follow up: Follow up with Primary Care Physician in 2-3 days. Special: Nursing home should do neurologic checks throughout the day."" -- 3. Review of Resident #79's comprehensive admission minimum data set (MDS), with an assessment reference date of 04/22/11, found in Section G the assessor encoded the resident as requiring the extensive physical assistance of two (2) or more persons with bed mobility. -- 4. Review of an occupational therapy evaluation form, signed by the occupational therapist on 04/18/11, found the following under the heading ""Summary and Assessment"": ""Res. (resident) evaluated this date for skilled OT (occupational therapy) (symbol for 'secondary') to Res & family wanting Res to return home. ... Res ... demonstrates decline /c ADL's, Fxnal (functional) mobility, (L) hand contracture at wrist PIP (proximal interphalangeal) & DIP (distal interphalangeal) jts (joints), & (L) UE (upper extremity) swelling. ..."" Review of an occupational therapy summary form, signed by the occupational therapist on 05/26/11, found the following under the heading ""Weekly Status"" related to the resident's ability to perform bed mobility: 04/18/11 - Initial Status - Dep (dependent) 04/26/11 - Dep 05/02/11 - Dep 05/10/11 - Dep 05/16/11 - Dep - Review of a physical therapy evaluation form, signed by a physical therapist on 04/16/11, found the following under the heading ""Summary and Assessment"": ""Resident presents /c (with) (L) (left) sided [MEDICAL CONDITION]. She [MEDICAL CONDITION] 2008. ... She has had a recent decline in function and would like to resume PT (physical therapy) in attempts to improve her (R) (right) sided strength so she can assist more /c transfers and (arrow pointing) her ability for toileting / dignity."" Review of a physical therapy summary form, signed by the physical therapist on 05/19/11, found the following under the heading ""Weekly Status"" related to the resident's ability to roll / turn (bed mobility): 04/16/11 - Initial Status - Max 2 04/23/11 - NT 04/30/11 - Max 2 05/07/11 - Max 2 05/14/11 - Max - In an interview on 06/01/11 at 4:30 p.m., the rehabilitation program supervisor (Employee #80) explained that ""Max 2"" meant ""maximum assist with two (2)."" -- 5. Review of the care plan, with the director of nursing (DON) at 3:30 p.m. on 06/01/11, revealed the following: - A problem statement on page 3 of 14 (quoted as typed): ""ADL Self care deficit as evidence by need for assist with ADLs related to left [MEDICAL CONDITION] (Created on: 4/15/2011)."" The goal associated with this problem statement was: ""Will maintain existing ADL self performance while working with therapy services to limit further decline daily thru next review (Date initiated: 4/25/2011)."" Interventions to assist the resident in achieving this goal included: ""... Encourage and/or assist to reposition frequently (Created on 4/15/2011). ... Uses Trapeze to help assist with mobility (Created on 5/17/2011). ..."" The care plan did not specify the amount of staff assistance Resident #79 required for performing bed mobility, in view of her inability to turn on her right side independently due to left-sided [MEDICAL CONDITION] and right-sided weakness. - - A problem statement on page 5 of 14 (quoted as typed): ""Falls due to impaired balance / poor coordination, [MEDICAL CONDITION] related to late effects [MEDICAL CONDITION] (Created on 4/15/2011)."" The goal associated with this problem statement was: ""Minimize risk of injury related to falls daily through next review (Date initiated: 5/15/2011)."" Interventions to assist the resident in achieving this goal were: ""Have commonly used articles within easy reach (Date initiated: 4/15/2011). PT as ordered (Dated initiated 4/15/2011). Bariatric mattress (Dated initiated: 5/15/2011)."" The care plan, again, did not specify the amount of staff assistance Resident #79 required for performing bed mobility, especially in view of the fact that the fall occurred while the resident was being turned / repositioned to facilitate incontinence care. Additionally, the only new intervention added after the fall was to provide the resident with a bariatric mattress. -- 6. Review of the kardex found on the computer kiosk, with a nursing assistant who was providing care for the resident on 06/02/11 at 3:00 p.m. (Employee #45), found the following under the heading ""ADL's / Restorative Care"" (quoted as typed): ""*ADL Assist - Usually 1 person with total assist (encourage resident to participate as able) (FYI)"" Employee #45 reported she would sometimes reposition the resident in bed without assistance, and sometimes the resident required two (2) staff, but it just depended on how close to the edge of the bed the resident was. -- 7. Review of documentation entered by nursing assistants in the task list, regarding the amount of assistance provided to Resident #79 for bed mobility for the period 05/03/11 through 05/14/11, found the resident was repositioned by two (2) staff members on twenty-seven (27) occasions and by only one (1) staff member on eleven (11) occasions. This information was reviewed with the MDS nurse and a nurse manager (Employees #93 and #54) on the mid-afternoon of 06/01/11. -- 8. On 06/01/11 at 4:15 p.m., the administrator provide a copy of the nurse aide job description (dated 08/02 and revised 02/08) and highlighted a sentence under the heading ""Safety and Sanitation"" that stated: ""Observes safety needs of patients as indicated in care plan."" He stated Resident #79 was to receive the assistance of one (1) staff person for bed mobility. Further review of the section titled ""Personal Nursing Care Responsibilities"" found the nurse aide's responsibilities included: ""Assists resident with lifting, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc., in keeping with specific resident safety needs."" Under the heading ""Special Nursing Care Responsibilities"", one (1) of the responsibilities was: ""Turns bedfast residents as instructed."" -- 9. Because the care plan did not instruct staff in the amount of assistance to be provided for bed mobility, and because the kardex stated the resident ""usually"" required only the assistance on one (1) person for bed mobility, there was no evidence that the facility provided instructions to the nurse aides to ensure the resident consistently received the amount of assistance she required to safely turn and reposition in bed, in view of her left-sided [MEDICAL CONDITION] and right-sided weakness. It was determined that the resident's fall from bed on the morning of 05/15/11 was an avoidable accident. (See also citation at F323.) -- During an interview on the early afternoon of 06/02/11, the DON confirmed the resident was provided a bariatric bed after the fall, so she would have more room to turn. .",2014-10-01
11364,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2009-07-02,246,D,,,MWZ111,"Based on observation, staff interview, and record review, the facility failed to ensure proper positioning of one (1) randomly observed resident in restorative dining. A resident in a scoot chair was observed eating lunch while the back of his scoot chair was in a reclined position. The reclined position of the chair back interfered with the resident's ability to reach his food. Resident identifier: #189. Facility census: 102. Findings include: a) On 06/29/09 at 12:25 p.m., observation found Resident #189 eating in the restorative dining room. The resident was seated in a scoot chair. The scoot chair's seat was low to the ground, and the backrest was observed to be in a reclined position. The table height was too high for the resident to comfortably reach his food. The resident, who was attempting to feed himself, was having difficulty reaching the food on the table and was spilling some food onto his chest. The resident, when observed on 07/02/09 at 12:30 p.m. in the restorative dining room., was again in the scoot chair seated at the table. The backrest to the chair was observed in a reclined position. The resident was observed having difficulty reaching the food on the table. When interviewed on 07/02/09 at 12:45 p.m., the speech language pathologist (SPL - Employee #17) stated the backrest to the scoot chair was ""all the way up"". She further stated, ""I sometimes put pillows behind his back."" The SPL walked over to the chair and raised up the backrest. The resident's medical record, when reviewed at 1:30 p.m. on 07/02/09, revealed a physician's for the scoot chair. A dietary note, dated 06/12/09, reported the resident consumes 59% of meals and requires supervision with meals. .",2014-04-01
11365,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2009-07-02,240,B,,,MWZ111,"Based on resident interview, observation, and staff interview, the facility failed to ensure residents received fresh ice and water every shift. This was evident for four (4) of four (4) sampled residents, three (3) of whom were located on the same hall. Resident identifiers: #57, #108, #6, and #31. Facility census: 102. Findings include: a) Resident #31 During an interview on 06/30/09, Resident #31 voiced a complaint of not having ice for his pitcher. He said he could not stand to drink the water that was not cold and elaborated that he will awaken from sleep and crave a cold drink, but many times there was no ice in his pitcher. He said he had not voiced complaints about this to anyone. He felt the facility should know to provide ice water to people who cannot easily get their own. He said there have been many times he had to get cold water from the bathroom in order to have a cold drink, and this may happen by day or by night. At 8:55 a.m. on 07/01/09, observation of his water pitcher found it contained only water, no ice. His pitcher was checked for ice again at 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., and no ice was present on any of these observations. Observations of every water pitcher on the same hall found none of the residents on that hall had ice in their pitchers. During an interview on 07/01/09 at 4:30 p.m., a nurse (Employee #139) stated ice was supplied to residents every shift. When informed that sampled residents had received no ice in their pitchers on day shift today, and currently none of the residents on the hall in question had ice, she stated she would take care of it immediately. b) Resident #6 Record review revealed Resident #6 was dependent on staff for all activities of daily living (ADLs) except eating. On 07/01/09, observations of her water pitcher, at 8:55 a.m., 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., found no fresh ice water at any time this day. This was reported to the nurse (Employee #139) at 4:30 p.m. on 07/01/09. c) Resident #108 Record review revealed Resident #108 was dependent on staff for all ADLs except eating. On 07/01/09, observations of her water pitcher, at 8:55 a.m., 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., found no fresh ice water at any time this day. This was reported to the nurse (Employee #139) at 4:30 p.m. on 07/01/09. d) Resident #57 Record review revealed Resident #57 was dependent on staff for all ADLs. On 07/01/09, observations of her water pitcher, at 8:55 a.m., 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., found no fresh ice water at any time this day. The water pitcher contained the same amount of liquid, nearly empty, at each check. This was reported to the nurse (Employee #139) at 4:30 p.m. on 07/01/09. .",2014-04-01
11366,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2009-07-02,252,D,,,MWZ111,"Based on observation and staff interview, the facility failed to provide a clean environment free from unpleasant odors as evidenced by the presence of a persistent odor of urine in a room shared by two (2) incontinent residents. This was evident for two (2) of four (4) sampled residents. Resident identifiers: #6 and #108. Facility census: 102. Findings include: a) Residents #6 and #108 share a room. Observations of the residents' shared room on 06/30/09, at 8:05 a.m., 1:42 p.m., and 2:15 p.m., revealed an unpleasant odor of urine that could be detected immediately upon entering the room. At 8:05 a.m., the odor seemed to be the strongest from Resident #6. At 1:42 p.m., the odor seemed to be coming from an afghan on the bed and the curtain separating the two (2) residents. At 2:15 p.m., the odor of urine was noted also from the wheelchair pad belonging to Resident #108, who had been sitting in the wheelchair. On all three (3) instances, the smell of urine was easily noticeable and could be detected immediately upon entering the room. On 07/01/09 at 11:45 a.m., the distinct odor of urine was detected immediately upon entering the room. During an interview at this time, a nursing assistant (Employee #93) stated she and other aides had noticed a bad smell in the room yesterday and, subsequently, Resident #108's mattress was changed. After the floor was mopped and the resident was showered, they still noticed the odor. She stated she did not believe the odor was coming from the pad in Resident #108's wheelchair, but she agreed she could smell the odor of urine in the curtain separating the residents. She immediately notified housekeeping. The housekeeping, upon arrival, smelled the curtain and also agreed it smelled like urine. She said they do terminal cleaning once every month, which includes taking down the curtains and washing them. She said Resident #6 will yell and throw things when that curtain is removed, as she always wants it pulled. She related she would use the second curtain in the room as a divider between the two (2) beds and take the malodorous curtain down and wash it today. .",2014-04-01
11367,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2009-07-02,242,D,,,MWZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, policy review, staff interview and record review, the facility failed to ensure one (1) of twenty-eight (28) Stage II sampled residents receive bi-weekly showers per resident request. Resident #133, who had an intestinal infection, reported she did not receive bi-weekly showers as requested, due to facility's infection control policy regarding [MEDICAL CONDITIONS] infection. Resident identifier: #133. Facility census: 102. Findings: a) Resident #133 Resident #133, when interviewed on 06/30/09 at 10:00 a.m., reported she has not been able to take a shower and get her hair washed for the past two (2) weeks. The resident stated she has an intestinal infection, and staff told her she could not take a shower due to the infection. Resident #133 stated, ""This makes me feel dirty and my hair looks terrible."" The director of nurses (DON - Employee #20) provided a copy of the facility's policy titled ""[MEDICAL CONDITION] Protocol"" on 07/01/09. Review of this, at 1:45 p.m. on 07/01/09, found no limitations on a resident's shower schedule during active infection. On 06/30/09 at 11:00 a.m., a licensed practical nurse (LPN - Employee #127), when interviewed, stated, ""Residents with [MEDICAL CONDITION] do not get showers due to loose stools."" On 07/01/09 at 2:45 p.m., the DON stated residents with [MEDICAL CONDITION] infection can have showers, and it is not the facility's policy to hold showers for residents with [MEDICAL CONDITION] infection. The DON further stated she needed to educate her staff regarding the current policy. Resident #133's medical record, when reviewed on 07/01/09 at 3:00 p.m., revealed a care plan for diarrhea dated 06/09/09. The interventions listed did not include withholding showers until the intestinal infection resolved. .",2014-04-01
2899,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2017-05-30,309,E,1,0,NRE111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, policy review and staff interview, the facility failed to ensure neurological assessments were completed after unwitnessed falls or falls where sustained head injury for two (2) out of six (6) residents. In addition, the facility also failed to schedule a nephrology consult for one (1) out of six (6) residents. Resident identifiers: #63, #13, #75. Facility census: 74. Findings include: a) Resident #63 Record review, on 05/22/17 through 05/30/17, revealed: --On 01/05/17 at 4:00 a.m., Incident and Accident Report revealed Resident #63 experienced a fall. According to the Incident and Accident report, Resident was found sitting on the floor of his room. Bed alarm was in place and alarming. Resident stated he was, Attempting to go to the bathroom. Also, according the the Incident and Accident Report, Neuro checks initiated per un-witnessed fall policy. --On 01/05/17 at 4:00 a.m., nursing noted revealed, Continued observation. Neuro checks. Resident also fell on [DATE] at 9:00 p.m. According to the Incident and Accident report, Resident was found sitting on the floor behind the nurses station. He was scooting around on the floor on his bottom. When I asked him what had happened he laughed and stated that he didn't know. --Resident also fell on [DATE] at 10:00 p.m. According to the Incident and Accident report, Reported to me .that Resident was found sitting against the bed in another patients (sic) room. Also according to the Incident and Accident Report, Neuro assessment performed and vital signs obtained. --Resident also fell on [DATE] at 4:00 a.m According to the Incident and Accident report, Resident was found to be sitting on the floor mat on the L (left) side of his bed, his back was leaned against the bed and he was facing the other bed in the room with his left straight out in front of him. According to the Facility's Neurological Assessment Policy, When a patient sustains an injury to the head and/or has an unwitnessed fall, neurological assessments will be performed every thirty (30) minutes for two (2) hours, then every one (1) hour for four (4) hours, then, every four hours for twenty-four (24) hours. According to the Neurological Assessment Flow Sheet dated 03/11/17 through 03/12/17, following Resident's fall, neurological assessment was performed at 9:00 p.m., 9:30 p.m., 10:00 p.m., and 10:30 p.m Vital signs, but not level of consciousness, pupil response, or motor functions, were obtained at 1:00 a.m., 2:00 a.m., and 3:00 a.m. Neurological assessment was performed at 7:00 a.m., 11:00 a.m., 3:00 p.m., and 7:00 p.m Neurological Assessment Flow Sheets were not provided for the unwitnessed falls on 01/05/17, 03/16/17, or 05/21/17. Director of Nursing (DON) was interviewed on 05/30/17, at 12:00 p.m DON stated he had performed an audit of unwitnessed falls and Neurological Assessment Flow Sheets. He stated he believed the nursing staff was performing and documenting neurological assessments as per the facility's Neurological Assessment Policy. However, he believed the Neurological Assessment Flow Sheets were not being put into the Resident's medical file after the form is completed. b) Resident #75 Record review on 05/22/17 through 05/30/17 of physician's orders [REDACTED]. According to the Progress Note written by the nurse practitioner (NP) #10 on 12/08/17, I will refer her to (nephrologist's name) with nephrology for evaluation and management. Discussed orders with nursing. The handwritten physician's orders [REDACTED]. The Nursing Note dated 12/09/16 stated, Resident has been given doses of [MEDICATION NAME] for short periods d/t (due to) CKD. (Nephrologist's name) consulted. The care plan evaluation dated 12/14/2016 states, Refer to (nephrologist's name) regarding CKD. According to the handwritten physician's orders [REDACTED]. Resident #75 was discharged the following day on 01/25/17. Resident #75 was not seen by the nephrologist at the facility. Interview with registered nurses (RN) #49 and #102 on 05/25/17 at 11:00 a.m. revealed consult orders are put on a communication sheet and the consultant physician's office is called by the unit clerk or by the medical records clerk. The nurses further stated that sometimes an appointment is made at the initial call and sometimes the consultant physician's office will call back with the appointment date and time. When the appointment date and time has been set, the appointment information is then entered into the computer as an order. The communication sheet was not put into the Resident's file. If the consultant physician does not call back with the appointment date and time, clinical judgment is used in deciding when to follow-up. Interview the nurse practitioner on 05/30/17, at 11:00 a.m. she stated she had no independent recollection of the incident. She thought that on 01/25/17, she probably realized the Resident had not been seen by the nephrologist yet, which prompted her to write the order to follow-up on the consult. b) Resident #13 Review of incident and accident reports from 05/22/17 thru 05/30/17 revealed Resident #13 experienced falls on the following dates: 02/22/17, 03/02/17, 03/24/17, and 05/17/17. --02/22/17 The incident and accident report stated on 02/22/17 at 9:45 p.m. Resident #13 was found in the floor beside her bed. She was found shortly after being placed in her bed for the night. The report stated the resident was assessed by a registered nurse (RN) for injury and that neurological checks were started. The resident's temperature, pulse, respirations and blood pressure was documented on the report as taken at 10:00 p.m. The resident was not transferred to a hospital. A change in condition-follow up form documented vital signs (temperature, respiration and blood pressure) were taken on 02/23/17 at 1:59 p.m. Vital signs were also taken on 02/24/17 at 4:28 a.m. and on 02/25/17 at 4:10 a.m. and at 2:00 p.m. Vital signs were also taken on 02/26/17 at 12:57 a.m. A neurological assessment flow sheet for 02/22/17 showed the following sections were to be completed (date, time, level of consciousness, pupil response, motor functions, pain response, vitals, observations and signature). The form was filled out incompletely on 02/22/17 at 10:00 p.m., 10:15 p.m., 10:30 p.m., 10:45 p.m., and on 02/23/17 at 11:45 p.m. The form contained no further assessments. --03/02/17 The incident and accident report stated that on 03/02/17 at 9:30 a.m., Resident was sitting in her w/c (wheelchair) when she bent over to pick something up off the floor and fell head first out of the chair onto the floor, hitting her head causing a contusion on the Lt. (left) side of forehead and a skin tear on Lt. (left) lower forearm, and a red area on Rt. (right) knee. Neuro checks initiated- no change from baseline. resident's baseline is alert but confused. The report documented that vitals (temperature, pulse, respiration, blood pressure were taken on 03/02/17 at 9:30 a.m. The neurological assessment flow sheet was not located for the unwitnessed fall that occurred on 03/02/17. --03/24/17 The incident and accident report stated on 03/24/17 at 12:00 a.m., Resident was found on knees at bedside, bed was in lowest position and floor mats were in place. Resident was assessed and vitals obtained and transferred back into bed. She obtained a 2cm x 0.5 cm skin tear to LFA (left forearm) which was cleansed with WCC (wound care cleanser), patted dry, sureprep no sting applied to periwound [MEDICATION NAME] gentle applied. The report documented that vitals (temperature, pulse, respiration, and blood pressure) were taken on 03/24/17 at 12:05 a.m. and at 6:43 a.m. On 03/24/17 the progress note at 12:00 p.m. indicated the resident was alert, awake and confused. A change in condition-follow up form had vital signs (temperature, respiration, blood pressure) documented as taken on 03/25/17 at 1:22 a.m., 12:59 p.m., 03/26/17 at 4:57 a.m., and at 10:54 a.m. The neurological assessment flow sheet was not located for the unwitnessed fall that occurred on 03/24/17. --05/17/17 The incident and accident report stated on 05/17/17 at 5:00 a.m., Resident was found lying on floor mat beside of her bed. Resident showed no signs of pain with movement. Resident is unable to move left leg which is unchanged due to polio as a child. Notified on call (name of nurse practitioner) and made aware of situation and she ordered stat (now) Xray of her hip, pelvic, and femur. Vital signs (temperature, pulse, respiration, and blood pressure) were documented as taken on 05/17/17 at 5:00 a.m. The neurological assessment flow sheet was completed incompletely on 05/17/17 at 5:00 a.m., 5:30 a.m., 6:00 a.m., 6:30 a.m., 7:00 a.m., 8:00 a.m., 9:00 a.m., 10:00 a.m., 11:00 a.m., 3:00 p.m., 7:00 p.m., 11:00 p.m., and on 05/18/17 at 3:00 a.m. and 7:00 a.m. On each of these dates/times the form had sections that were not completed. The facility's fall management policy (revision date 03/15/16) revealed in section 5.2.1 that neurological assessments should be performed on all unwitnessed falls and witnessed falls with head injury. The neurological assessment policy revision date (10/01/12) stated neurological assessments would be performed when a patient had an injury to the head and/or an unwitnessed fall. The policy stated this assessment would be performed every 30 minutes for two (2) hours then every hour for four (4) hours then every four (4) hours x 24 hours. This would equal a total of 30. During an interview at 12:10 p.m. on 05/30/17 with the director of nursing (DON) revealed that the DON felt his nursing staff were completing neurological assessments per facilty policy. He felt the documentation just was not being put in the medical record. At the time of exit no other information was provided.",2020-09-01
2900,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2017-05-30,514,D,1,0,NRE111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to ensure the medical record was complete for one (1) of six (6) residents medical records reviewed. The incontinence diary for Resident #12 was incomplete. Resident's identifier: #12. Facility census: 74. Findings include: a) Resident #12 On 05/22/17 through 05/30/17, a medical record review revealed Resident #12 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Three-Day Continence Management-Diary was initiated on 04/21/17, with the following instructions: Initiate within 72 hours of identifying incontinence or completion of treatment for [REDACTED]. Example: CB/5:30. On 04/22/17 of twelve (12) possible documentation of continence or incontinence, seven (7) lacked documentation. On 04/24 through 04/25/17, four (4) areas lacked documentation respectively. In addition, on 04/26/17 only four (4) areas were documented with eight (8) lacking documentation. On 05/30/17 at 2:45 p.m., in an interview with the Director of Nursing (DON), when shown the Three-Day Continence Management-Diary, the DoN was in agreement the documentation was incomplete.",2020-09-01
2901,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2019-10-02,584,E,1,0,EBS011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview the facility failed to ensure each resident was afforded the right to a safe, clean, comfortable and homelike environment. This was true for three (3) of 43 patient rooms. Facility census: 70. Findings included: a) Observation An initial tour of the facility beginning at 11:05 a.m. on 09/30/19 found the 300 hall of the facility in need of the housekeepers attention. The issues were identified: --room [ROOM NUMBER] There was debris on the floor which needed to be cleaned up. --room [ROOM NUMBER] There was debris on the floor which included food which appeared to be from the breakfast meal, There was eggs and cereal on the floor. There was also a shiny wet looking spot which appeared to be a spill that was all ready dried to the floor. --room [ROOM NUMBER] There was dried orange substance on the floor which was a spill that was all ready dried to the floor. b) Interview A tour with the Nursing Home Administrator at 11:13 a.m. on 09/30/19 confirmed the issues identified above. He instructed the housekeeper to tend to the issues.",2020-09-01
2902,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2017-11-03,241,D,0,1,YOX711,"Based on observation and staff interview, the facility failed to ensure that each resident had a dignified dining experience. During the breakfast meal on 11/01/17 at 8:03 a.m. Nurse Aide (NA) # 69 was observed feeding Resident #22, #76 and Resident #83. NA #69 feed each resident while she was standing. This was a random opportunity for discovery. Resident Identifiers: #22, #76, and #83. Facility Census: 74. Findings Include: a) Observations of the morning meal on 11/01/17 beginning at 8:03 a.m. and concluding at 8:34 a.m. found NA #69 was feeding Resident #22, Resident #76 and Resident #8. NA #69 was not seated while feeding the residents she was in a standing position. An interview with NA #69 at 8:34 a.m. on 11/01/17 confirmed she should not have been standing to feed the residents. She stated, It is just a habit.",2020-09-01
2903,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2017-11-03,253,E,0,1,YOX711,"Based on observation and staff interview, the facility failed to ensure a homelike, sanitary environment. Resident #24's wheelchair was covered with debris. In addition, the arm rest of the wheelchair was torn. Several tears were observed in the seat of a facility stationary upholstered chair in Resident #130's room. These random observations were found during Stage 1 of the Quality Indicator Survey (QIS) and remained during Stage 2 of the QIS. Resident identifiers: #24 and #130. Facility census: 74. Findings include: a) Resident #24 Observation of the resident's wheelchair at 2:21 p.m. on 10/30/17, found the frame of the wheelchair, the webbing on the sides of the wheelchair, the seat covering, the spokes of the wheels, and both hand brakes were covered with dried food, lint, hair, and other debris. A pink dried substance was present on the webbing on the sides of the wheelchair. The positioning cushion in the wheelchair was also dirty with several large dried stains. The left arm rest on the wheelchair was torn in several places. A second observation with the director of nursing (DON) at 10:59 a.m. on 11/01/17, confirmed all of the above observations made at 2:21 p.m. on 10/30/17, were still present. The DON said, I can't argue with that, I will make sure it is cleaned. b) Resident #130 Observation of the resident's room at 1:19 p.m. on 10/30/17, found several tears in the facility owned, stationary, upholstered chair in the resident's room. At 1:02 p.m. on 11/01/17, observation with the DON confirmed the chair was torn in numerous places, exposing the white padding underneath.",2020-09-01
2904,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2017-11-03,272,D,0,1,YOX711,"Based on staff interview and medical record review, the facility failed to ensure a complete and accurate comprehensive minimum data set (MDS) for Resident #20 in the care area of dental status and services. This was true for one (1) of three (3) resident's reviewed for the care area of dental status and services during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #20. Facility census: 74. Findings include: a) Resident #20 Observation on the resident during Stage 1 of the Quality Indicator Survey (QIS), at 2:05 p.m. on 10/30/17, found her bottom denture was moving up and down during conversation. When asked if she had any problems with her dentures, the resident replied, Yes, my denture is loose and they can't do anything about it. Review of the most recent, annual MDS with an assessment reference date (ARD) of 08/09/17, found the facility did not code the resident as having, broken or loosely fitting full or partial denture on section (L) b. Review of the resident's current care plan, updated on 03/07/17, found the problem: Resident is at risk for oral health or dental care problems as evidenced by loose fitting lower denture, also wears an upper denture. (Name of Resident) refused to f/u (follow through) with dentist regarding loose fitting denture. At 8:45 a.m. on 11/01/17, Registered Nurse, MDS coordinator (RN) #74 confirmed the 08/09/17 MDS was coded incorrectly in the oral/dental status section. RN #74 said it was just a mistake as she was aware the resident's bottom denture did not fit properly.",2020-09-01
2905,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2017-11-03,278,D,0,1,YOX711,"Based on record review, resident interview, and staff interview, the facility failed to conduct an accurate quarterly Minimum Data Set (MDS) assessment for one (1) of four (4) residents reviewed for the care area of urinary incontinence during Stage 2 of the Quality Indicator Survey (QIS). The quarterly MDS assessment for Resident #57 did not accurately identify the resident's urinary continence status. Resident identifier: #57. Facility census: 74. Findings include: a) Resident #57 Resident #57 triggered for review in Stage 2 of the QIS due to a decline in bladder continence. The admission MDS with Assessment Reference Date (ARD) 07/16/17 documented Always continent in the area of Urinary Continence. The quarterly MDS with ARD 09/16/17 documented Occasionally incontinent (less than 7 episodes of incontinence) in the area of Urinary Continence. The ADL Record for Resident #57 for the month of September, (YEAR), in the category of Bladder indicated C for each shift on 09/01/17-09/10/17. According to the legend on the ADL Record, C = Continent. From 09/11/17-09/15/17 the ADL Record appeared to indicate [NAME] for night shift. On the legend on the ADL Record, there was no E. Beginning 09/16/17 through 09/30/17, the ADL Record in the category of Bladder indicated I for night shift. According to the legend on the ADL Record, I = incontinent. For this time period, I was indicated for day shift on (MONTH) 17, 19, 20, 21, 25, 26, 27, and 28. The remaining dates indicated C for day shift. For this time period, I was indicated for evening shift on (MONTH) 27. There was no documentation for Bladder for evening shift on 09/28/17. The remaining dates indicated C for evening shift. For the month of (MONTH) (YEAR), the ADL Record for Resident #57 in the area of Bladder indicated C for each shift on each day. On 10/31/17 at 4:10 p.m., the Director of Nursing (DoN) was interviewed to determine if Resident #57's decline in urinary incontinence was assessed and whether measures were taken to restore continence. The DoN stated he would look into the matter. On 10/31/17 at 4:30 p.m., the DoN stated the Es and Is on Resident #57's ADL Record for the area of Bladder were charted in error. The DoN stated [NAME] did not occur on the legend and therefore, was an error. The DoN stated the Is, meaning incontinence, were also charted in error. He stated he had spoken to Resident #57, who denied ever being incontinent. Resident #57 was interviewed on 11/01/17 at 9:20 a.m. Resident #57 confirmed she has never been incontinent. She stated she always ambulates to the bathroom to urinate. During an interview on 11/01/17 at 10:00 a.m., MDS nurse #74 stated the look-back period for the quarterly MDS with ARD 09/16/17 showed one episode of incontinence on the ADL Record. She stated that is the reason Occasionally incontinent was coded on the quarterly MDS. When questioned about the Es on the ADL Record, MDS nurse #74 stated the Es might have looked like Cs. She stated she would speak with the DoN to determine if the MDS needed to be corrected. On 11/01/17, MDS nurse #74 corrected the quarterly MDS with ARD 09/16/17. The Urinary Continence section was changed to Always continent.",2020-09-01
2906,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2017-11-03,282,D,0,1,YOX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, family interview and staff interview, the facility failed to implement Resident #22's care plan relating to her need to be transferred with a total mechanical lift with the assistance of two (2) staff members. The facility also failed to implement Resident #51's care plan in the area of impaired communication. This was true for two (2) of 22 residents care plans during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifiers: #22 and 51. Facility Census: 74. Findings include: a) Resident #22 A review of Resident #22's medical record at 12:57 p.m. on 10/31/17 found a Lift Transfer Reposition assessment dated [DATE]. This assessment indicated Resident #22 was to be transferred with a total lift with the assistance of two (2) staff members. Further review of the record found an Activity of Daily Living care plan. Review of the interventions associated with this care plan found the following intervention, Requires Total Assistance using medium lift pad and two staff members This intervention was added to the care plan on 09/13/17 the same date the lift assessment was completed. Observations of Resident #22 at 9:11 a.m. on 11/01/17 found the resident to be sitting up in her wheelchair. Nurse Aide (NA) #80 was in Resident #22's room. Resident #22 asked her to put her to bed. NA #80 left the room and then reentered the room and closed the door. NA #80 was the only NA in the room at this time and there was no mechanical lift observed in the room. At 9:15 a.m. on 11/01/17 NA #69 entered the room and stated she was looking for Resident #22. At 9:20 a.m. on 11/01/17 both NA #80 and #69 exited the room and Resident #22 was observed to be in her bed. NA #80 and NA #69 was asked how they transferred Resident #22 from the wheelchair to the bed. NA #69 stated, I don't know I was talking with the roommate. NA #80 stated, Her lift pad was crooked and I had to just lift her up by myself and put her into the bed. NA #80 was asked how Resident #22 should have been transferred and she stated, Usually we use a mechanical lift but because her lift pad was crooked I could not use it. So I just had lift her into the bed by myself. b) Resident #51 During Stage 1 of the QIS on 10/30/17 at 12:40 p.m., two (2) family members of Resident #51 were interviewed while they were visiting. The family members stated Resident #51's hearing aids had been missing for approximately two (2) weeks. The family members stated facility staff was aware the hearing aids were missing. The family members did not know what actions were being taken by the facility to locate or replace the missing hearing aids. However, the family members reported they were not Resident #57's Medical Power of Attorney (MPOA). Resident #51 was interviewed on 10/31/17 at 3:00 p.m. The resident could understand speech if spoken loudly and clearly in close proximity. Resident #51 confirmed her hearing aids had not been located. She stated, It's awful not being able to hear. During an interview on 10/31/17 at 3:30 p.m., Registered Nurse #59 stated she thought Resident #51's hearing aids had been located. She stated she thought one of the hearing aids was broken when it was found. Social Worker (SW) #10 and the facility Administrator were interviewed on 10/31/17 at 3:35 p.m. The SW stated he had been informed by nursing staff that one of Resident #51's hearing aids was broken. He had asked the nursing staff to bring him the broken hearing aid so it could be repaired. However, he had not received the hearing aid for repair. The facility administrator stated he would ask facility staff to attempt to locate Resident #51's hearing aids. He stated the hearing aids would be replaced if they were not able to be located or would be repaired if broken. A note written by SW #7 on 10/31/17 at 4:27 p.m., stated, On this date it was reported that (Resident #51)'s hearing aids were missing. A referral was made to ST (Speech Therapy) for evaluation and use of pocket talker. SW contacted daughter/MPOA regarding missing hearing aids and replacing them. Daughter (name) stated she does not want her to sit through a hearing test, but had the hearing aids made at (outside facility). SW let MPOA know we would use pocket talker in the interim and would contact (outside facility) for replacement or use our vendor Audiologist and Hearing Aid Services. MPOA was agreeable to this and stated the pocket talker may be the best long-term solution. SW left a message with (outside facility) to replace hearing aids as soon as possible. Will continue to follow-up. During an interview on 11/01/17 at 1:50 p.m., SW #10 stated parts of Resident #51's hearing aids had not been located. He stated the provider that originally supplied the hearing aids had been consulted and was coming to the facility to assess the resident for replacement of her hearing aids. Resident was provided with a pocket talker until her hearing aids were replaced. A note written by SW #10 on 11/02/17 at 8:59 a.m., stated, This SW contacted (outside facility) yesterday morning and spoke with (provider's name) about replacing resident's hearing aids. (Provider's name) advised he wanted to come to the center to see exactly what hearing aid parts resident has to they can get the correct replacement parts. This SW received a message from the (outside facility) yesterday afternoon advising that (provider name) was busier than expected and would come to the center today. During an interview on 11/02/17 at 10:00 a.m., Resident #51 was wearing the pocket talker. She stated she was hearing a little bit better with the use of the pocket talker. Resident #51's care plan had the focus of impaired communication. Interventions included Ensure that the patient is wearing hearing aid(s) right and left and Assist resident to insert hearing aide (sic). During an interview on 11/01/17 at 2:00 p.m., this care plan focus and interventions were reviewed with the Director of Nursing. However, the interventions could not have been implemented when the resident's hearing aids were missing. On 11/01/17, Resident #51's care plan was revised in the area of impaired communication. The intervention was added for Staff to assist resident with Pocket Talker to improve hearing when awake. The interventions to Ensure that the patient's is wearing hearing aid(s) right and left and Assist resident to insert hearing aide (sic) were removed.",2020-09-01
2907,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2017-11-03,313,E,0,1,YOX711,"Based on family interview, resident interview, staff interview,and record review, the facility failed to provide assistive devices to maintain hearing abilities to one (1) of one (1) residents reviewed for the care area of hearing during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #51. Facility census: 74. Findings include: a) Resident #51 During Stage 1 of the QIS on 10/30/17 at 12:40 p.m., two (2) family members of Resident #51 were interviewed while they were visiting. The family members stated Resident #51's hearing aids had been missing for approximately two (2) weeks. The family members stated facility staff was aware the hearing aids were missing. The family members did not know what actions were being taken by the facility to locate or replace the missing hearing aids. However, the family members reported they were not Resident #57's Medical Power of Attorney (MPOA). Resident #51 was interviewed on 10/31/17 at 3:00 p.m. The resident could understand speech if spoken loudly and clearly in close proximity. Resident #51 confirmed her hearing aids had not been located. She stated, It's awful not being able to hear. During an interview on 10/31/17 at 3:30 p.m., Registered Nurse #59 stated she thought Resident #51's hearing aids had been located. She stated she thought one of the hearing aids was broken when it was found. Social Worker (SW) #10 and the facility Administrator were interviewed on 10/31/17 at 3:35 p.m. The SW stated he had been informed by nursing staff that one of Resident #51's hearing aids was broken. He had asked the nursing staff to bring him the broken hearing aid so it could be repaired. However, he had not received the hearing aid for repair. The facility administrator stated he would ask facility staff to attempt to locate Resident #51's hearing aids. He stated the hearing aids would be replaced if they were not able to be located or would be repaired if broken. A note written by SW #7 on 10/31/17 at 4:27 p.m., stated, On this date it was reported that (Resident #51)'s hearing aids were missing. A referral was made to ST (Speech Therapy) for evaluation and use of pocket talker. SW contacted daughter/MPOA regarding missing hearing aids and replacing them. Daughter (name) stated she does not want her to sit through a hearing test, but had the hearing aids made at (outside facility). SW let MPOA know we would use pocket talker in the interim and would contact (outside facility) for replacement or use our vendor Audiologist and Hearing Aid Services. MPOA was agreeable to this and stated the pocket talker may be the best long-term solution. SW left a message with (outside facility) to replace hearing aids as soon as possible. Will continue to follow-up. During an interview on 11/01/17 at 1:50 p.m., SW #10 stated parts of Resident #51's hearing aids had not been located. He stated the provider that originally supplied the hearing aids had been consulted and was coming to the facility to assess the resident for replacement of her hearing aids. Resident was provided with a pocket talker until her hearing aids were replaced. A note written by SW #10 on 11/02/17 at 8:59 a.m., stated, This SW contacted (outside facility) yesterday morning and spoke with (provider's name) about replacing resident's hearing aids. (Provider's name) advised he wanted to come to the center to see exactly what hearing aid parts resident has to they can get the correct replacement parts. This SW received a message from the (outside facility) yesterday afternoon advising that (provider name) was busier than expected and would come to the center today. During an interview on 11/02/17 at 10:00 a.m., Resident #51 was wearing the pocket talker. She stated she was hearing a little bit better with the use of the pocket talker.",2020-09-01
2908,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2017-11-03,323,D,0,1,YOX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview the facility failed to ensure Resident #22's environment over which it had control was as free from accident hazards as possible. Resident #22 was transferred from her wheelchair to the bed without the use of a mechanical lift as indicated by her most recent lift assessment and plan of care. This was true for one (1) of four (4) residents reviewed for the care area of accidents during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #22. Facility Census: 74. Findings Include: a) Resident #22 A review of Resident #22's medical record at 12:57 p.m. on 10/31/17 found a Lift Transfer Reposition assessment dated [DATE]. This assessment indicated Resident #22 was to be transferred with a total lift with the assistance of two (2) staff members. Observations of Resident #22 at 9:11 a.m. on 11/01/17 found the resident to be sitting up in her wheelchair. Nurse Aide (NA) #80 was in Resident #22's room. Resident #22 asked her to put her to bed. NA #80 left the room and then reentered the room and closed the door. NA #80 was the only NA in the room at this time and there was no mechanical lift observed in the room. At 9:15 a.m. on 11/01/17 NA #69 entered the room and stated she was looking for Resident #22. At 9:20 a.m. on 11/01/17 both NA #80 and #69 exited the room and Resident #22 was observed to be in her bed. NA #80 and NA #69 was asked how they transferred Resident #22 from the wheelchair to the bed. NA #69 stated, I don't know I was talking with the roommate. NA #80 stated, Her lift pad was crooked and I had to just lift her up by myself and put her into the bed. NA #80 was asked how Resident #22 should have been transferred and she stated, Usually we use a mechanical lift but because her lift pad was crooked I could not use it. So I just had lift her into the bed by myself.",2020-09-01
2909,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2017-11-03,371,F,0,1,YOX711,"Based on observation and staff interview, the facility failed to ensure food was served under sanitary conditions to prevent the spread of food borne illness. Food service carts, used to deliver meals to the 100 and 400 hallways had a build up of dirt and debris. The steam table in the serving area of the dining room was dirty. Dirty serving trays were left beside the serving line. Stains and food debris were on the serving counter. The steam table had charred debris in the water wells. The chrome back splash on the steam table had a build up of grease and dirt. Wheeled serving carts, containing food items used during the noon meal had a build up of debris. The resident pantry refrigerator contained a roast beef sandwich with no date to indicate when the sandwich was prepared and no date to indicate when to discard. This practice had the potential to effect all residents at the facility. Facility census: 74. Findings include: a) Food carts Observation of the food carts, used to deliver the noon meals to 100 and 400 halls, at 12:24 p.m. on 10/30/17 found streaks of dried substances that could be scraped off with a fingernail, scattered over the carts. Employee #25, a food service employee, confirmed the carts needed to be cleaned. She stated she thought the carts were cleaned before she left on 10/20/17. The director of nursing (DON)observed the carts at 12:25 p.m. on 10/30/17 and said, The carts could certainly be cleaner. b) Noon meal service in the dining room Observation of the tray line on 10/30/17 at 12:40 p.m., with the dietary manager, found the dietary staff placed the noon meal, consisting of sandwiches, potato salad, and fruit on the stainless steel, stationary, steam table located inside the dining room. Coffee stains and scattered cheerios were present on the counter of the serving station. Round dirty serving trays were stacked on the counter beside the steam table during the meal service. Grease stains and dirt were found on the back splash of the steam table. Black charred debris were in the three (3) water wells of the steam table. Two (2) wheeled serving carts; one used for bread, lettuce and tomatoes, and one used for the bowls of fruit were covered with debris and dried food on the legs and tray area of both carts. c) Resident pantry Observation of the refrigerator in the resident pantry with activity aide, #14, at 11:00 a.m. on 10/30/17, found a wrapped roast beef sandwich, prepared by the facility, with no date to identify when the sandwich was prepared and no date to indicate when the sandwich should be discarded.",2020-09-01
2910,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2017-11-03,441,D,0,1,YOX711,"Based on observations and staff interview the facility failed to maintain an effective infection control program to prevent the spread of illnesses. During the lunch meal on 10/30/17 Resident #25's meal was sat on his over the bed table. Resident #25's urinal was sitting on the over the bed table beside his meal. This was a random opportunity for discovery during the dining observation of the noon time meal on 10/30/17. Resident identifier: #25. Facility census: 74. Findings include: a) Resident #25 Observation of the noon time meal on 10/30/17 beginning at 12:15 p.m. found Resident #25 was served his meal at 12:18 p.m. by Nurse Aide #50. She sat Resident #25's meal up on his over the bed table and did not remove the resident's urinal from his over the bed table. At 12:20 p.m. on 10/30/17 NA #50 returned with Resident #25's drinks and placed them on the Residents over the bed table and still did not remove the Residents urinal which was still sitting on the Residents over the bed table beside his meal. An interview with NA #50 at 12:21 p.m. on 10/30/17 confirmed she had not removed the urinal from the residents over the bed table when she served him his meal. She stated, I forgot to move his urinal. She then went into the residents room and moved Resident #25's urinal from the over bed table.",2020-09-01
2911,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2017-11-03,514,E,0,1,YOX711,"Based on record review, resident interview, and staff interview, the facility failed to ensure a complete and accurate medical record for two (2) of 22 residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The activity assessment was not accurate for Resident #45. The Activities of Daily Living (ADL) Record was not accurate for Resident #57. Resident Identifiers: #45 and #57. Facility Census: 74. Findings include: a) Resident #45 The resident's most recent recreation assessment, dated 08/03/17, was reviewed at 8:52 a.m. on 11/01/17. The assessment noted the resident was interviewed for activity preferences and the resident said she liked to read the newspaper, occasionally. In section C of the assessment, the resident responded to the question: What are things that we can do or provide that will make you feel more comfortable at this center? According to the documentation on the recreation assessment, the resident responded with, Newspaper. The assessment noted the resident would be encouraged to attend socials, spiritual, crafts and bingo. Review of the resident's current care plan found the problem, Resident exhibits or is at risk for limited meaningful engagement related to sensory loss. The goal associated with the problem is: Resident will increase social engagement as evidenced by participation in one to one visits, small groups and unstructured involvement with peer/family/friends/staff. Interventions included: Provide interventions such as sensory props and small groups that address resident's strengths and abilities for participation. Likes music and groups, recreation staff will continue to invite, assist and encourage to attend, and update accordingly. Further review of the resident's most recent minimum data set (MDS), an annual with an assessment reference date (ARD) of 08/06/17, found the resident is rarely/never understood. The brief interview for mental status (BIMS) could not be completed with the resident. The resident's cognitive skills for daily decision making was severely impaired. The resident has both long and short term memory problems. At 11/01/17 at 1:45 p.m., the activity director, AD #26 said the resident attends sensory groups. She likes music, sometimes exercise. We try to encourage sensory and food related activities. AD #26 reviewed the activity assessment, dated 08/03/17, and confirmed the resident could not read the newspaper and participate in bingo. She verified the assessment was incorrect. At 2:22 p.m. on 11/01/17, the activity assistant, AA #14 verified the resident could not read a newspaper and most likely would not have asked for a newspaper. She added the resident would be unable to attend bingo. AA #14 confirmed the assessment did not correspond with the resident's current interests and abilities. AA #14 did not believe the resident could have requested a newspaper and AA #14 did not believe the resident would be capable of reading a newspaper due to her cognitive loss. c) Resident # 57 Resident #57 triggered for review in Stage 2 of the QIS due to a decline in bladder continence. The admission MDS with Assessment Reference Date (ARD) 07/16/17 documented Always continent in the area of Urinary Continence. The quarterly MDS with ARD 09/16/17 documented Occasionally incontinent (less than 7 episodes of incontinence) in the area of Urinary Continence. The ADL Record for Resident #57 for the month of September, (YEAR), in the category of Bladder, indicated C for each shift on 09/01/17-09/10/17. According to the legend on the ADL Record, C = Continent. From 09/11/17-09/15/17 the ADL Record appeared to indicate [NAME] for night shift. On the legend on the ADL Record, there was no E. Beginning 09/16/17 through 09/30/17, the ADL Record in the category of Bladder indicated I for night shift. According to the legend on the ADL Record, I = incontinent. For this time period, I was indicated for day shift on (MONTH) 17, 19, 20, 21, 25, 26, 27, and 28. The remaining dates indicated C for day shift. For this time period, I was indicated for evening shift on (MONTH) 27. There was no documentation for Bladder for evening shift on 09/28/17. The remaining dates indicated C for evening shift. For the month of (MONTH) (YEAR), the ADL Record for Resident #57 in the area of Bladder indicated C for each shift on each day. On 10/31/17 at 4:10 p.m., the Director of Nursing (DoN) was interviewed to determine if Resident #57's decline in urinary incontinence was assessed and whether measures were taken to restore continence. The DoN stated he would look into the matter. On 10/31/17 at 4:30 p.m., the DoN stated the Es and Is on Resident #57's ADL Record for the area of Bladder were charted in error. The DoN stated [NAME] did not occur on the legend and therefore, was an error. The DoN stated the Is, meaning incontinence, were also charted in error. He stated he had spoken to Resident #57, who denied ever being incontinent. Resident #57 was interviewed on 11/01/17 at 9:20 a.m. Resident #57 confirmed she has never been incontinent. She stated she always ambulates to the bathroom to urinate.",2020-09-01
2912,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2018-11-09,558,D,0,1,LOBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to provide reasonable accommodate for residents needs related to call light and vision. This had the potential to affect three (3) of 18 sampled residents. Resident Identifers: #64, 119, and #28. Facility census 71. Findings included: a) Resident #64 In an interview on 11/06/18 at 9:03 AM, Resident #64 stated he had seen the eye doctor and he was suppose to receive a new pair of glasses and he never received the glasses. A review of Resident #64's care plan with an revision date of 10/12/18, revealed that Resident #64 has vision impairment related to capsule cataract. The care plan said Resident #64 wears glasses. A review of the consultation report revealed Resident #64's vision was evaluated on 06/12/18 by a Optometry Specialist (physician name). Resident #64 is to receive a new pair of prescription glasses. When social worker (SW) #43 was asked on 11/07/18 at 12:48 PM, about whether Resident #64 was evaluated by the Optometry Specialist (physician name) and is to receive prescription glasses. The SW #43, stated that Resident #64 had been seen by the Optometry Specialist (physician name) but his glasses may not have came as of yet. c) Resident #28 On 11/05/18 at 3:04 PM, Resident #28, stated that she had seen the eye doctor and she was suppose to receive a new pair of glasses and she never received the glasses. The quarterly Minimum Data Set (MDS) with ARD 09/01/18, Resident #28 Brief interview for mental status (BIMS) is 15. A BIMS score of 13-15 means the Resident is cognitively intact. The MDS indicates Resident #28 wears corrective lens. Under Resident #28's additional active [DIAGNOSES REDACTED]. A review of the consultant report for Resident #28, revealed Optometry Specialist (physician name) evaluated Resident #64's vision on 08/14/18. The report revealed Resident #28 had cataract, diabetic retinopathy, dry eye syndrome, and [MEDICAL CONDITION]. The complete eye report also revealed Resident #28 had vitreal floaters, retinal exudates and Trichiaisis (in which the eye lash grow inwards toward the eye). The report also revealed the resident has eye symptoms of: glare, tired eyes, burning, dryness, foreign body sensation, itching, blurred vision distance, blurred vision near, and loss of side vision. Resident #28 is to receive a new pair of prescription glasses. On 11/07/18 at 12:51 PM, Employee #43 social worker(SW) was asked whether he had followed up on why Resident #28's glasses were not sent from the Optometry Specialist ( physician name). SW #43, stated that Resident #28 was evaluated on 08/14/18, and Resident #28 is to receive glasses, but they may not have came as of yet. On 11/07/18 at 3:20 PM, SW #43 revealed that Resident #64 and #28 were to get glasses. When SW #43 was asked how long does it takes for a resident here to obtain a pair of glasses. SW #43 made no comment. The social worker #43 was asked whether he called the Optometry Specialist (physician name) about the where about's of Resident #64 and #28's prescription glasses. SW #43, stated that he had. SW #43 was then asked what did the optometry Specialist (physician name) tell you. SW#43, stated that they are working on making the glasses. SW #43 confirmed that he did not document this information anywhere, nor follow back up to see when Resident #64 and #28 would be receiving their prescription glasses. The director of nursing (DoN) #58 on 11/08/18 at 10:30 AM, provided a email between SW #43 and the Optometry specialist, (physician name) had send back and forth to each other with the date of 10/15/18. The Optometry specialist (physician name), stated that Resident #28 and #64's glasses were dispensed to the facility. The Administrator #20 was informed on 11/08/18 at 11:15 AM, about Resident #28 and #64's not receiving their prescription glasses. The Administrator acknowledge this was too long to wait for the glasses to be provided. The Administrator confirmed that he just found out about the glasses were dispensed to the facility, and no one knows where the glasses went. The Administrator stated at that point we failed to check on the where/ when Resident #64 and #28 would receive their glasses. At the time of exit on 11/09/18 at 2:45 PM, the Administrator #20 stated that he had received Resident 64's and #28's written prescription for glasses. The Administrator #20, stated that he was going to find out the residents' preference for glasses and find someone near by to obtain glasses for Resident #64 and #28. b.) Resident #118 A review of the medical record for Resident #118 showed staff assessed the resident to be a fall risk related to impaired mobility, tremors and use of antipsychotic medication. A care plan intervention to assist Resident #118 was to place call light within reach while in bed or close proximity to the bed, dated 11/06/2018 Observation of Resident #118's room on 11/05/18 at 11:12 AM and 11/06/18, at 08:50 AM, revealed the call light attached to the wall unit approximately over five feet high. The resident's mobility was via wheelchair and the resident was receiving physical therapy to improve gait. An interview with Resident #118, on 11/05/18 at 11:12 AM, revealed the call light was attached on the wall and was too high to reach while in her wheel chair. Resident #118, stated at this time, I can't get to that. An interview with the Director of Nursing (DON), on 11/07/18 at 08:20 AM, verified the call bell should not have been attached/clipped at the wall but made more accessible to the resident. The DON further stated that is not what we expect. I will address that.",2020-09-01
2913,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2018-11-09,584,D,0,1,LOBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide a safe and sanitary environment. Rooms 301, 303, 307, 309, 312 and 405 had multiple chips of wood absent from the corner of the doors as well as black scuff marks on the walls. Resident #23 had torn wheelchair arms. Room Identifiers: 301, 303, 307, 309, 312, 405. Resident Identifier: #23. These practices had the potential to affect a limited number of residents. Facility census: 71. Findings included: a) Resident Rooms On 11/05/18 at 11:58 AM an observation found room [ROOM NUMBER]'s bathroom door with scuffs at bottom and the outside door had chips of wood missing at the corner of doors. room [ROOM NUMBER]'s outside door had chips of wood cut out at the corner of the door. room [ROOM NUMBER]'s had scuffs on the only bathroom door and room [ROOM NUMBER]'s bathroom door was scuffed and the outside door was chipped. In addition, room [ROOM NUMBER] had black marks on the wall. On 11/06/18 at 9:15 AM room [ROOM NUMBER]'s door scuffed the floor when attempting to shut the door. A tour with the Administrator in Training (AIT) on 11/09/18 at 9:52 AM, was in agreement the doors were chipped and black marks were on the walls of room [ROOM NUMBER]. b.) An observation of room [ROOM NUMBER], on 11/08/18, at 03:15 PM, verified a large black scuff mark on the wall adjacent to the night stand. The Maintainence Supervisor was present during the observation and verified the large scuff mark. An interview with the Maintenance Supervisor, on 11/08/18 at 03:26 PM, revealed safety rounds are conducted every week to allow inspections of every room per month. It was sated at this time, repair is constant. c.) An observation on 11/09/18 at 03:18 PM revealed torn and frayed paddding on the left arm of Residentt #23's wheel chair. An interview on 11/08/18 at 03:22 PM, with the Maintenance Supervisor, verified the wheelchair arm being torn and frayed. The Maintenance Supervisor stated at this time, I will fix that.",2020-09-01
2914,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2018-11-09,726,D,0,1,LOBQ11,"Based on personnel file review, policy and procedure review and staff interview, the facility failed to ensure that two of three nurses reviewed had performance evaluations completed annually to ensure staff competency. Employee Identifiers: RN#23 and LPN#12. Findings included: a.) A review of the policy and procedure titled HR16 Performance Appraisal Program: Employee showed: Managers would meet with employees at least annually to conduct a performance appraisal and in-service education would be provided based on the outcome of the review. b.) RN#23 A review of the personnel file for RN#23 showed a hire date of 07/28/18. Further review of the personnel file , showed no evidence of a performance evaluation. An interview, with the facility Administrator, on 11/09/18, at 11:40 AM, when requested the performance evaluation, it was stated, It does not exist, I do not have her performance appraisal. c.) LPN#12 A review of the personnel file for LPN#12 showed a hire date of 07/12/11. Further review of the file showed the most recent performance evaluation dated 12/13/13. An interview with Administrator, on 11/09/18, at 12:38 PM, verified the last performance evaluation was done on 12/13/18. It was stated by the administrator at this time, I can not validate I have had an evaluation for LPN#12 in the last year.",2020-09-01
2915,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2018-11-09,730,E,0,1,LOBQ11,"Based on review of personnel files, review of policy and procedure, and staff interview, the facility failed to ensure that performance of four of five nursing assistants were evaluated on an annual basis and failed to ensure two of five nursing assistants completed the required 12 hours of training. Employee identifiers: NA#36, NA#109, NA#11, NA#26 and NA#39. Findings included: a.) A review of the policy and procedure titled HR16 Performance Appraisal Program: Employee showed: Managers would meet with employees at least annually to conduct a performance appraisal and in-service education would be provided based on the outcome of the review. b.) NA#36 A review of the personnel file reviewed 11/09/18, showed NA#36 was hired by the facility 8/13/15. Further review of the file, there was no current performance evaluation. An interview with the Administrator on 11/09/18, at 11:40 AM, revealed no performance evaluation was available for review. Further review of the personnel file for NA#36, revealed the employee had completed 7 hours of training instead of the required 12 hours of annual training. An interview with the Administrator on 11/09/18, at 02:20 PM, verified NA#36 did not have the required 12 hours of training. c.) NA#109 A review of the personnel file for NA#109 showed a hire date of 06/22/10. Further review of the file showed no current performance evaluation for NA#109. Additionally, NA#109's file showed the employee had not completed the 12 hours of annual training. The file showed the employee had completed 6.5 hours. An interview, with the Administrator, on 11/09/18, at 2:20 PM, verified there was no current performance evaluation and NA#109 had not received the required number of training hours. d.) NA#11 A review of the personnel file for NA#11, showed a hire date of 09/25/18. Further review showed the last performance evaluation completed for NA#11 to be 05/14/16. An interview with the administrator, on 11/09/18, at 12:25 PM, verified the employee had not been evaluated on an annual basis and 05/14/16 was the most recent evaluation. e.) NA#26 A review of the personnel file for NA#26 , showed a re-hire date of 05/13/16. Further review of the file showed a performance evaluation for NA#26, dated and signed on 05/13/16. An interview with Administrator , on 11/09/18, at 02:20 PM, verified there was no current performance evaluation for NA#26. f.) NA#39 A review of the personnel file for NA#39 showed a hire date of 05/20/16. Further review showed no performance appraisal noted in the file. An interview with the Administrator , on 11/09/18, at 02:20 PM, verified there was no performance evaluation available.",2020-09-01
2916,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2018-11-09,842,D,0,1,LOBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medical record was accurate and complete related to personal belongings and the lack of evidence of discharge instructions for Resident #69. This practice was true for three (3) of 18 sample residents. Resident identifier: #25, #28 and #69. Facility census: 71. Findings included: a) Resident #25 Review of the medical record on 11/07/18 at 3:51 PM, revealed Resident #25 had no Inventory of Personal Effects (IPE) form located in medical record. Resident #25 was admitted on [DATE]. Interviewed the Director of Nursing (DoN) on 11/07/18 at 4:20 PM regarding missing IPE form. On 11/07/18 at 4:44 PM, received Resident #25 IPE form from Medical Records. Medical Records stated that the IPE form was thinned from the Resident #25's medical record. The IPE had only Resident #25's name and room number on the form. The date of admission, faculty representative signature and Resident #25's signature was not completed. b) Resident #28 Review of Resident #28's medical record on 11/07/18 at noon, revealed Resident #28 was admitted on [DATE] with an IPE form dated 09/25/15. Resident #28's IPE contained no resident signature or date. Interviewed Bookkeeper #105 on 11/07/18 at 12:32 PM stated that the IPE dated for 09/25/15 is the only one in the medical record. Bookkeeper #105 on 11/07/18 at 1:39 PM confirmed no additional IPE forms have been completed. Interviewed Nurse Aide (NA) #9 on 11/07/18 at 2:05 PM regarding procedure with new admissions and processing of personal belongings. NA #9 stated Oh we write them down on that piece of paper and throw it in their chart. c) Resident #69 On 11/09/18 at 9:05 AM a review of the medical record on 11/08/18 revealed no evidence of the discharge plan for Resident (R) #69. In an interview with the Director of Nursing (DON) on 11/09/18, the DON stated that a new nurse did not make a copy of the discharge instructions for the medical record. In addition, the DON stated that the facility had changed computer systems for discharges and were unable to retrieve the information. Evidence of the discharge instructions were not produced when exiting the facility on 11/18/18 at 2:50 PM.",2020-09-01
2917,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2018-11-09,880,F,0,1,LOBQ11,"Based on observation and staff interview, the facility failed to have a negative air flow system to prevent cross contamination of linens. This practice had the potential to affect all residents who reside in the facility. Facility census: 71. Findings included: a) Laundry Observed the Laundry Department on 11/08/18 at 8:19 AM. The air flow observation revealed air flowed from the soiled linen room of Laundry Department into the clean linen room of the Laundry Department. Nursing Home Administrator (NHA) on 11/08/18 at 08:40 AM observed the air flow problem. Accompanying the NHA was the Environment Director #75 to also observe the air flow problem. The NHA concurred this is an air flow problem and maintenance will start working to get the air flow issues corrected immediately.",2020-09-01
2918,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2019-12-04,561,D,0,1,KNB211,"Based on resident interview, record review and staff interview the facility failed to ensure a resident had the opportunity to exercise autonomy regarding her bathing preferences. This was true for one (1) of two (2) residents reviewed for the care area of choices during the long - term care survey. Resident identifier: #54. Facility census: 71. Findings include: a) Resident #54 An interview with the resident at 11:07 AM on 12/02/19, revealed the resident received two (2) showers a week but would like to have more showers. The resident stated, It is not possible to get any more. The resident explained the facility only schedules two (2) showers per week. Record review found the resident's most recent minimum data set (MDS), a quarterly, with an assessment reference date (ARD) of 11/14/19, found the resident scored a 14 on the brief interview for mental status (BIMS.) A score of 14 indicates the resident is cognitively intact. On 12/03/19 at 01:30 PM, the Registered Nurse (RN) supervisor #18 said, We have a shower schedule allotted for 2 showers a week, if we were able to accommodate it, we could give more. RN #18 verified the Resident's shower days were Tuesdays and Saturdays. The resident's shower schedule is determined by the room in which the resident resides. RN #18 said the surveyor should talk to RN #54 who does the shower schedules. An interview with RN #54 on 12/03/19 at 2:06 PM, found guest services is to interview the residents to determine their preferences for bathing. On 12/03/19 at 4:07 PM, the guest services director, [NAME] #82 said she interviews residents upon admission to determine if the shower time and the day of the shower are acceptable. [NAME] #82 said when Resident #54 was admitted she was not working at the facility. At 4:14 PM on 12/03/19, [NAME] #82 said an interview with Resident #54 revealed the Resident wanted to have a shower every other day. On 12/04/19 at 8:36 AM, the Director of Nursing (DON) said the resident is able to make her needs known and she should have told someone if she wanted more showers. At the close of the survey at 12:15 PM on 12/04/19, no further information was provided.",2020-09-01
2919,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2019-12-04,578,E,0,1,KNB211,"Based on record review and interview, the facility failed to fully complete the Physician's Orders for Scope of Treatment (POST) form for residents with advance directives. This deficient practice was found for three (3) of three (3) residents reviewed for the care area of advance directives. Resident identifiers: #53, #46, #44. Facility census: 71. Findings included: a) Resident #53 A review of Resident #53's Physician's Orders for Scope of Treatment (POST) form on 12/02/19 at 12:06 PM revealed that Resident #53 wished to receive intravenous (IV) fluids for a trial period of no longer than ___. The blank (___) was not filled out to indicate the length of the trial period. During an interview on 12/03/19 at 4:09 PM, the facility's Director of Nursing (DoN) stated, I would agree, when asked if Resident #53's POST form was incomplete. No further information was provided prior to exit. b) Resident #46 A review of Resident #46's POST form on 12/02/19 at 12:07 PM revealed that Resident #46 wished to receive IV fluids for a trial period of no longer than ___. The blank (___) was not filled out to indicate the length of the trial period. During an interview on 12/03/19 at 4:09 PM, the facility's DoN stated, I would agree, when asked if Resident #46's POST form was incomplete. No further information was provided prior to exit. c) Resident #44 A review of Resident #44's POST form on 12/02/19 at 2:12 PM revealed that Resident #44 wished to receive IV fluids for a trial period of no longer than ___. The blank (___) was not filled out to indicate the length of the trial period. During an interview on 12/03/19 at 4:09 PM, the facility's DoN stated, I would agree, when asked if Resident #44's POST form was incomplete. No further information was provided prior to exit.",2020-09-01
2920,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2019-12-04,583,E,0,1,KNB211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to protect the rights of privacy and confidentiality of personal records of residents. The facility failed to protect personal information and medical treatment of [REDACTED]. This was a random opportunity for discovery. The failed practice affected more than unlimited number of residents. Resident identifiers: #4, #14, #38, #44, #414 and #415. Facility census: 71. Findings included: An observation, on 12/02/19 at 12:30 PM, revealed a list of resident names that sat on top of the 400 hall med cart. The list titled, [MEDICAL TREATMENT] Residents: contained six (6) [MEDICAL TREATMENT] resident names visible by walking past the med cart sitting in 400 hallway. The list contained residents names, days of pick-up, times of pick-up and phone numbers. The residents listed on the paper titled, [MEDICAL TREATMENT] Residents: included: --Resident #4 --Resident #14 --Resident #44 --Resident #414 --Resident #415 --Resident #38 An interview with Licensed Practical Nurse (LPN) #11, on 12/02/19 at 12:30 PM, confirmed the list should have been turned over and not visible to the general public.",2020-09-01
2921,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2019-12-04,656,E,0,1,KNB211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to develop and / or implement comprehensive care plans for five (5) of twenty-one (21) residents reviewed. Care plans were not implemented for the care areas of pressure ulcers, accidents, respiratory, and nutrition. In addition a care plan was not developed to include dietary restrictions. Resident identifiers: #21, #12, #14, #3, and #413. Facility census: 71. Findings include: a) Resident #21 Record review revealed the resident was admitted to the facility on [DATE] with pressure ulcers to both the left and right heels. Both areas were staged as DTI's (deep tissue injuries). Review of a skin integrity report revealed both areas healed on 02/26/19. Review of the current care plan, found an intervention to off load/float heels while in bed, initiated on 02/11/19 to prevent new skin breakdown. Observation of the resident with the Director Of Nursing (DON) at 7:32 AM on 12/03/19, found the resident was in bed. Both heels were resting on the mattress. No device was present to off load/ float the heels. The DON confirmed the residents heels should be floated and directed nursing staff to take care of this issue. b) Resident #3 A record review on 12/03/19 at 2:20 PM, revealed a care plan that stated, Provide diet as ordered/tolerated- Regular/liberalized Dysphasia advance. 2 handle sip cup w/ lid, no straws. An observation, on 12/03/19 at 2:35 PM, revealed an 18-ounce water bottle with straw that sat on the bedside table over bed. A four (4) ounce Vanilla Shake Supplement with Resident #3's name label on carton sat on the bedside table over bed. The Vanilla Shake supplement was open with straw in carton. The Vanilla Shake supplement was picked up and was half empty. Both containers of fluid were easily accessible to Resident #3. There was no two (2) handled sip cup available in room. An interview with Administrator, on 12/03/19 at 2:55 PM, confirmed straws at bedside table in contradiction of care plan that stated no straws. Administrator immediately removed both the water bottle with straw and the half empty Vanilla Shake Supplement carton with straw from the resident's room. c) Resident #413 An interview with Resident #413, on 12/02/19 at 11:00 AM, revealed I am not supposed to have straws the speech therapist said don't drink out of straws because of trouble swallowing and aspiration. An observation on 12/02/19 at 11:00 AM, revealed two (2) straws on bedside table. One (1) straw was laying on the bedside table the second straw was in the provided water bottle. Resident demonstrated what happens when drinking from a straw which resulted in coughing. An interview with Resident #413, on 12/03/19 at 8:20 AM, revealed Resident was provided a straw for fluid intake. Resident #413 stated, I was given a straw again. An observation on 12/03/19 at 8:20 AM, revealed a straw in water pitcher. A dietary tray slip was on the bedside table. The dietary slip was immediately reviewed and stated, NO STRAWS. An interview with Speech Therapist #70, on 12/03/19 at 8:40 AM, confirmed a physician's orders [REDACTED]. The physician order [REDACTED]. NO STRAWS. A medical record review, on 12/03/19 at 9:05 AM, revealed the care plan did not include the physician order [REDACTED]. An interview with Licensed Practical Nurse (LPN) #11, on 12/03/19 at 9:25 AM, revealed Resident #413 should not have straws but, It's no big deal if he does. LPN #11 stated, I would expect to see no straws on the care plan. Interview with Director of Nursing (DoN), on 12/03/19 at 10:55 AM, stated he was unaware of Resident #413's physician order [REDACTED]. d) Resident #12 A review of the current comprehensive care plan for Resident #12 noted the resident to be at risk for falls due to cognitive loss and poor safety awareness, impaired balance and strength. An intervention was noted for the resident to have bilateral fall mats in place. An observation on 12/03/19 at 07:37 AM, revealed Resident #12 in bed with the fall mat to the right of the resident, propped up against the wall and not on the floor as ordered. On 12/03/19, at 07:55 AM, an interview with the DON verified the fall mat was propped against the wall and was not in place as ordered. e) Resident #14 A review of the current comprehensive care plan for Resident #14 noted the resident to exhibit or at risk for respiratory complications with an intervention for oxygen to be administered as needed. An observation, on 12/02/19 at 10:55 AM, revealed Resident #14 was receiving oxygen (O2) via nasal cannula at 4 liters per minute. An additional observation, on 12/03/19 at 08:00 AM revealed Resident #14 was receiving O2 at 4L/min via nasal cannula. An interview with the Director of Nursing (DON), on 12/03/19 at 08:00 AM verified the O2 flow rate to be at 4L/min but should have been set at 3 L/min. A review of the physician's orders [REDACTED].#14 was to receive O2 at 3L/min per nasal cannula continuous.",2020-09-01
2922,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2019-12-04,657,D,0,1,KNB211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to revise resident care plans to reflect changes in tube feeding orders and pressure ulcer status. This deficient practice was found for two (2) of 21 sampled residents reviewed during the survey. Resident identifiers: #53, #21. Facility census: 71. Findings included: a) Resident #53 A review of Resident #53's physician's orders [REDACTED].#53 was to receive a tube feeding of [MEDICATION NAME] 1.5 (a calorically dense tube feeding formula) at 60 milliliters (mL) per hour for 20 hours per day. The start date for the order was 11/09/19. On 12/03/19 at 2:20 PM the [MEDICATION NAME] 1.5 was observed to be running as ordered by the physician. On 12/03/19 at 4:13 PM Resident #53's care plan was reviewed with the facility's Director of Nursing (DoN). On page nine (9) of the care plan, an intervention revised on 11/14/19 directed to provide [MEDICATION NAME] 1.5 (a low-residue tube feeding formula used for patients with increased calorie and protein needs) at 45 mL per hour. The DoN stated that he would see what he could find out about this discrepancy between the care plan and the physician's orders [REDACTED].>On 12/03/19 at 4:19 PM the DoN agreed that the care plan had not been revised to reflect Resident #53's current tube feeding orders, stating, True statement. No further information was provided prior to exit. b) Resident #21 Record review found the resident was admitted to the facility on [DATE] with three (3) pressure ulcers: A deep tissue injury (DTI) to the right heel, A DTI to the left heel, and A DTI to the coccyx. All 3 areas healed on 02/26/19. Review of the current care plan, updated on 11/25/19 found the problem: Resident at risk for skin breakdown related to actual pressure ulcer, advanced age (greater than 75), decreased activity, incontinence, limited mobility. On 12/03/19 07:32 AM, the resident's licensed practical nurse (LPN) verified the resident did not have any pressure ulcers. We use Z guard on the coccyx as a treatment for [REDACTED]. On 12/03/19 07:58 AM, the Registered Nurse (RN), clinical reimbursement coordinator, RN #32 confirmed the resident does not have any pressure ulcers and the care plan should have been updated a history of past pressure ulcers.",2020-09-01
2923,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2019-12-04,677,D,0,1,KNB211,"Based on family interview, record review, and staff interview, the facility failed to ensure a resident who was dependent upon staff for bathing, received scheduled showers. This was true for one (1) of three (3) residents review for the care area of activities of daily living (ADL) care. Resident identifier: #21. Facility census: 71. Findings include: a) Resident #21 An interview with the resident's responsible party at 12:06 PM on 12/02/19, revealed the resident did not always receive her scheduled two (2) showers a week. On 12/03/19 at 10:20 AM, Registered Nurse (RN) #18 said the resident should receive a shower on Wednesdays and Sundays. Bathing activity is documented on the Resident's ADL record, completed by the nursing assistants. A review of the ADL records for the months of October, (MONTH) and (MONTH) 2019, with RN #18 found the following: In (MONTH) 2019, the resident received one (1) shower on 10/02/19. The resident received seven (7) bed baths. In (MONTH) 2019, the resident received one shower on 11/03/19. The resident received seven (7) bed baths during the month of November. In (MONTH) 2019, the resident received one bed bath on 12/02/19. At 10:42 AM on 12/03/18, RN #18 confirmed the resident is totally dependent upon staff for bathing. RN #18 said she did not know why the resident did not receive 2 showers as week as scheduled. RN #18 said the process is as follows: If a resident refuses a shower the nursing assistant is to tell the hall nurse. Sometimes the hall nurse will also talk to the resident. Either the nurse or the nursing assistant should document the resident refused a shower. RN #18 verified she could find no documentation indicating the resident refused any showers. On 12/04/19 at 8:48 AM, the Director of Nursing said he was aware of problems with documentation of scheduled showers, so he instituted a new policy around the end of last month. His new policy included the nursing assistant notifying the resident's licensed nurse of bathing refusals. The licensed nurse should then talk to the resident to verify the shower refusal. Documentation of a refusal is to occur.",2020-09-01
2924,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2019-12-04,684,K,0,1,KNB211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the physician orders. The facility failed to ensure care was delivered for residents who are at high risk of aspiration. Medications were left at the bedside table for the resident to self-administer. This was done without a physician order [REDACTED]. The failed practice affected two (2) of twenty-one (21) residents. Resident identifiers: #3 and #413. Facility census: 71. Two immediate jeopardies were called for this deficient practice. 1. Immediate Jeopardy #1 A nurse failed to remain in Resident #413's room during the administration of medications. This resident had a history of [REDACTED]. Consultation with the State Agency, on 12/03/19 at 1:15 PM, revealed that a determination of Immediate Jeopardy was identified. The Immediate Jeopardy was called with the facility's Administrator at that time. An acceptable Plan of Correction (P[NAME]) was approved and the immediacy of this deficient practice was abated on 12/03/19 at 3:35 PM. The P[NAME] included the following interventions: -The Nurse Practioner evaluated Resident #413 at 2:45 PM to ensure respiratory status remained baseline there was no evidence of aspiration and no correction required. -The Licensed Practical Nurse (LPN) #11 was re-educated regarding not leaving medications at the bedsides as per policy by the unit manager immediately upon discovery at 10:00 AM. -All residents of the facility had the potential to be affected. Director of Nursing (DON) and Unit Managers conducted rounds of all residents' rooms on 12/03/19 at 1:45 PM and no additional medication was left at the bedsides. - All licensed and certified nursing staff and dietary staff including agency on duty will be re-educated starting on 12/03/19 at 2:00 PM by the Practice Development Specialist with a posttest to validate understanding regarding ensuring the resident environment remains free of accident hazards. -Starting 12/03/19 the DON/designees will conduct observation rounds to include meal tray and room observations daily, across all shifts two (2) times including weekends, then three (3) times weekly for two (2) weeks then randomly thereafter to ensure licensed nurse does not leave medications at the bedsides. -Results of the observations will be reported to the DON/designee monthly to the Quality improvement Committee for additional follow up and an or in-servicing until the issue is resolved. Consultation with the State Agency, , revealed that a determination of Immediate Jeopardy was identified. The Immediate Jeopardy was called with the facility's Administrator at that time. An acceptable Plan of Correction (P[NAME]) was approved and the immediacy of this deficient practice was abated . The P[NAME] included the following interventions: An acceptable Plan of Correction (P[NAME]) was approved on 12/03/19 at 1:15 PM and the immediacy of this deficient practice was abated on 12/03/19 at 3:30 PM. The survey team began monitoring the implementation of the abatement P[NAME] at 1:15 PM. The scope and severity of the deficient practice was reduced to a [NAME] upon the acceptance of the abatement plan of correction. 2. Immediate Jeopardy #2 Consultation with the State Agency, on 12/03/19 at 3:45 PM, revealed a determination of Immediate Jeopardy was identified for this practice affecting Resident #3 and #413. The Immediate Jeopardy was called with the facility's Administrator at that time. The Abatement P[NAME] included the following interventions: --The nurse Practioner evaluated resident #3 at 4:30 PM and Resident #413 at 2:45 PM to ensure respiratory status remained baseline there was no evidence of aspiration and no correction required. --The Director of Nursing (DON) and all Unit Managers conducted rounds of all residents' rooms 12/03/19 at 3:45 PM to ensure residents who has no straw orders were without straws at bedside without any corrective action immediately upon discover. --All licensed and certified nursing staff and dietary staff including agency on duty will be re-educated starting on 12/03/19 at 4:00 PM by the Practice Development Specialist with a post test to validate understanding regarding the facility must ensure the resident receives treatment and care in accordance with professional standards of practice. --Starting 12/03/19 the DON/designees will conduct observation rounds to include meal tray and room observations daily, across all shifts two (2) times including weekends, then three (3) times weekly for two (2) weeks then randomly thereafter. --Results of the observations will be reported to the DON/designee monthly to the Quality improvement Committee for additional follow up and an or in-servicing until the issue is resolved. An acceptable Plan of Correction (P[NAME]) was approved at 4:15 PM on 12/03/19 and the immediacy of this deficient practice was abated on 12/03/19 at 5:20 PM. The survey team began monitoring the implementation of the abatement P[NAME] at 4:15 PM. The scope and severity of the deficient practice was reduced to a [NAME] upon the acceptance of the abatement plan of correction. Findings included: a) Resident #413 - Immediate Jeopardy #1 A policy review titled, NSG305 Medication: Administration: General with revision date 11/01/19, was reviewed on 12/04/19. The policy stated, Remain with patient until administration is complete. Do not leave medications at the patient's bedside. An interview with the Resident, on 12/02/19 at 11:00 AM, revealed the nurses leave medications at the bedside table for self-administration on most days. An observation at the time of the interview, on 12/02/19 at 11:00 AM, revealed an empty plastic medication cup on bedside table in front of the Resident. An interview with Speech Therapist (ST) #70, on 12/03/19 at 8:40 AM, revealed a modified [MEDICATION NAME] swallow test had been completed on the Resident on 10/24/19. The test was completed because of the resident's history of aspiration and swallowing issues. The ST stated the test showed decreased laryngeal elevation and incomplete laryngeal vestibular closure. The Resident is a 2 on the Aspiration Scale meaning thin liquids do enter the airway. A record review, on 12/03/19, at 9:00 AM, revealed no self-administration of medications on the Physician Orders, Kardex, or Care Plan. Further observation, on 12/03/19 at 9:20 AM, revealed Resident #413 was self-administering his own medications. The nurse was not in the room at the time of the observation. An interview with the Resident at the time of the observation, on 12/03/19 at 9:20 AM, revealed the nurse left my medications for me to take. Continued observation, on 12/03/19 at 9:21 AM, revealed Licensed Practical Nurse (LPN) #11 walked into the Resident's room. LPN #11 was interviewed and asked if the Resident self-administered his own medication. The LPN replied, Yes, I check back periodically to make sure he took them all. An Interview with Director of Nursing (DoN), on 12/03/19 at 10:55 AM, confirmed Resident #413 does not have a physician order [REDACTED]. An interview with LPN #11, on 12/03/19 at 11:10 AM, confirmed the list of medications that were given to the Resident at 9:00 AM. LPN #11 confirmed the following medications were self- administered. -Aspirin 81 mg -Duloxetine [MEDICATION NAME] Capsule delayed release 60 milligrams (mg) -[MEDICATION NAME] 5 mg [MEDICAL CONDITION] Do not handle med if pregnant or may become pregnant - [MEDICATION NAME] 25 mg give 0.5 tablet 2 X [MEDICAL CONDITION] to 125 mg - Tylenol 500 mg - Vitamin D3 400 units - [MEDICATION NAME] 25-100 mg II b) Resident #3 - Immediate #2 A record review, on 12/03/19 at 2:20 PM, revealed a [DIAGNOSES REDACTED]. A physician order [REDACTED]. The Care Plan stated, Provide diet as ordered/tolerated- Regular/liberalized Dysphasia advance. 2 handle sip cup w/ lid, no straws. The care plan, with revision date of 07/17/19, stated, Resident has impaired decline in cognitive function or impairment thought processes with a global deterioration score of four (4) related to cognitive loss/dementia. Resident #3 lacks capacity. A Nutritional Assessment, completed on 12/03/19, stated, Diet order: dysphasia advance Intakes excellent x lookback- 100% Food snacks BID b/t meals House supplement ordered TID- consuming 75-100% per [DATE] handle sip cup w/ lid, no straws Fluids encouraged per staff . An observation of the Resident's room, on 12/03/19 at 2:35 PM, revealed an 18-ounce water bottle with a straw that sat on the bedside table over the Resident's bed. The water bottle had 10 ounces of water in it. A four (4) ounce Vanilla Shake Supplement with Resident's name label on the carton was also on the bedside table. The Vanilla Shake Supplement was open with a straw in the carton. The Vanilla Shake Supplement was observed to be half empty. Both containers of fluid were easily accessible to Resident #3. A two handled sip cup was not observed to be available in the room at the time of the observation. An interview and observation with the Administrator, on 12/03/19 at 2:55 PM, in the Resident's room, confirmed there were straws in the Resident's water bottle and supplement on the Resident's bedside table. The Administrator immediately removed the water bottle and the half empty Vanilla Shake Supplement carton with straw from the resident's room. The Administrator stated the straws should not have been available for the Resident. The Administrator stated the Nurses Aides pass the water and supplements out to residents and would have provided the straws. c) Resident #413 - Immediate Jeopardy #2 An interview with the Resident, on 12/02/19 at 11:00 AM, revealed I am not supposed to have straws the speech therapist said don't drink out of straws because of trouble swallowing and aspiration. The Resident stated, the staff continues to bring me straws after I have voiced many concerns to them about not being allowed to have them. An observation of the Resident's Room, on 12/02/19 at 11 AM, revealed two (2) straws on the bedside table. One (1) straw was lying on the bedside table and the other straw was in the provided water bottle. The Resident demonstrated what happened when he drank from a straw which resulted in a coughing episode. Another interview with the Resident, on 12/03/19 at 8:20 AM, revealed the Resident was provided a straw for fluid intake. The Resident stated, I was given a straw again. Further observation of the Resident's Room, on 12/03/19 at 8:20 AM, revealed a straw in the Resident's water pitcher. A dietary tray slip with the Resident's name on it was on the bedside table. The dietary slip was immediately reviewed and stated, NO STRAWS. An interview with Speech Therapist (ST) #70, on 12/03/19 at 8:40 AM, revealed a modified [MEDICATION NAME] swallow test had been completed on the Resident on 10/24/19. The test was completed because of the resident's history of aspiration and swallowing issues. The ST stated the test showed decreased laryngeal elevation and incomplete laryngeal vestibular closure. The Resident is a 2 on the Aspiration Scale meaning thin liquids do enter the airway. The speech therapist confirmed a physician's orders [REDACTED]. A medical record review, on 12/03/19 at 9:05 AM, revealed the Resident's Kardex and Care Plan did not include the order for no straw use which was dated for 10/28/19. The Resident was admitted to the facility on [DATE] with assessments completed upon admission. Resident #413 scored a 13 on the Brief Interview for Mental Status (BIMS) Assessment demonstrating little to no cognitive impairment. The Resident also had a [DIAGNOSES REDACTED]. An interview with Registered Nurse (RN) #18, on 12/03/19 at 9:16 AM, revealed the Kardex is the main communication tool concerning patient care for all Nurse Aides. An interview with the Dietary Manager (DM), on 12/03/19 at 9:18 AM, revealed a diet order was provided to her in (MONTH) of 2019 for the Resident not to have straws. The DM then stated the order was communicated daily and with each meal on a Diet Tray Ticket which included the words NO STRAWS. An interview with Nurse Aide (NA) #105, on 12/03/19 at 9:24 AM, revealed she was the aide caring for the Resident. When asked about the Resident's straw restriction the NA stated, I have no idea if he is allowed to have straws or not. The NA further stated, I will have to check with the nurse. An interview with Licensed Practical Nurse (LPN) #11, on 12/03/19 at 9:25 AM, revealed Resident #413 does have a physician's orders [REDACTED]. The LPN stated he should not have straws, but it is no big deal if he does. She then further stated he is a grown man and can make his own decisions. The LPN stated the straw restriction was not on the current care plan would expect to see the straw restriction included. Interview with Director of Nursing (DON), on 12/03/19 at 10:55 AM, stated he was unaware of the Resident's physician order [REDACTED]. The facility failed to ensure care was delivered for residents who are at high risk of aspiration. Straws were being provided to residents who were ordered not to use them due to their risk of aspiration. The risk of aspiration pose an immediate risk to the health and life of the residents. In addition, a resident was identified as self-administering medications without monitoring/oversigtn, an assessment or physician order. This resident was identified through assessment and diagnostic testing as an aspiration risk. The lack of monitoring/oversight, assessment or a physician order [REDACTED].",2020-09-01
2925,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2019-12-04,689,D,0,1,KNB211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to provide an environment free from accident hazards over which they had control. A nurse failed to remain in Resident #413's room during the administration of medications. Resident identifiers: #413 and #12. Room identifier: 400 Hall Supply Room. Facility census: 71. Findings included: a) Resident 413 A policy review titled, NSG305 Medication: Administration: General with revision date 11/01/19, was reviewed on 12/04/19. The policy stated, Remain with patient until administration is complete. Do not leave medications at the patient's bedside. An interview with the Resident, on 12/02/19 at 11:00 AM, revealed the nurses leave medications at the bedside table for self-administration on most days. An observation at the time of the interview, on 12/02/19 at 11:00 AM, revealed an empty plastic medication cup on bedside table in front of the Resident. An interview with Speech Therapist (ST) #70, on 12/03/19 at 8:40 AM, revealed a modified [MEDICATION NAME] swallow test had been completed on the Resident on 10/24/19. The test was completed because of the resident's history of aspiration and swallowing issues. The ST stated the test showed decreased laryngeal elevation and incomplete laryngeal vestibular closure. The Resident is a 2 on the Aspiration Scale meaning thin liquids do enter the airway. A record review, on 12/03/19, at 9:00 AM, revealed no self-administration of medications on the Physician Orders, Kardex, or Care Plan. Further observation, on 12/03/19 at 9:20 AM, revealed Resident #413 was self-administering his own medications. The nurse was not in the room at the time of the observation. An interview with the Resident at the time of the observation, on 12/03/19 at 9:20 AM, revealed the nurse left my medications for me to take. Continued observation, on 12/03/19 at 9:21 AM, revealed Licensed Practical Nurse (LPN) #11 walked into the Resident's room. LPN #11 was interviewed and asked if the Resident self-administered his own medication. The LPN replied, Yes, I check back periodically to make sure he took them all. An Interview with Director of Nursing (DoN), on 12/03/19 at 10:55 AM, confirmed Resident #413 does not have a physician order [REDACTED]. An interview with LPN #11, on 12/03/19 at 11:10 AM, confirmed the list of medications that were given to the Resident at 9:00 AM. LPN #11 confirmed the following medications were self- administered. --Aspirin 81 mg --Duloxetine [MEDICATION NAME] Capsule delayed release 60 milligrams (mg) --[MEDICATION NAME] 5 mg [MEDICAL CONDITION] --[MEDICATION NAME] 25 mg give 0.5 tablet 2 X [MEDICAL CONDITION] to 125 mg --Tylenol 500 mg --Vitamin D3 400 units --[MEDICATION NAME] 25-100 mg II b) Resident #12 An observation on 12/02/19 at 02:03 PM, revealed Resident #12 was in bed and had bilateral floor mats on the floor beside the bed. The mat on the resident's left side slid when stepped on. This was verified with an interview with NA #35 at this time. An interview with NA #35 on 12/03/19 at 09:27 AM noted yesterday, (12/02/19), the fall mat was an issue and further stated it had been laid down on the floor incorrectly. NA#35 stated I should have known better. A record review for Resident #12, noted the comprehensive care plan addressed poor safety awareness and notes the resident is to have bilateral floor mats. An observation on 12/03/19 at 07:37 AM, revealed Resident #12 in bed with the fall mat to the right of the resident, propped up against the wall and not on the floor as ordered. On 12/03/19, at 07:55 AM, an interview with the DON verified the fall mat was propped against the wall and was not in place as ordered. c) 400 Hall Storage Room A random observation of the 400 Hall Storage Room , on 12/02/19 at 11:40 AM, revealed the room was unlocked and accessible to anyone. The room contained the following items: --Twenty-seven (27) containers of Medline Anti-Perspirant with the warning Keep out of reach of children-If accidentally swallowed get medical help or contact a poison control center right away. --Twenty-Four (24) containers of Medline Mouthwash with the warning Keep out of reach of children-If accidentally swallowed get medical help or contact a poison control center right away. --Twenty-Eight (28) containers of Medspa Aftershave with the warning Keep out of reach of children-For external use only. --Eight (8) bottles of Provon Ultimate Shampoo and Body Wash with the warning Caution-keep out of eyes-If accidentally swallowed get medical help or contact a poison control center right away. --Eighteen (18) containers of Colgate [MEDICATION NAME] Toothpaste with the warning Keep out of reach of children-If accidentally swallowed get medical help or contact a poison control center right away. --Six (6) containers of [MEDICATION NAME] Oral Rinse with the warning Keep out of reach of children-Do not swallow. --Ninety (90) capped razors An interview with the Director of Nursing (DON), on 12/02/19 at 11:55 AM, revealed the supply room is normally locked. The DON stated the staff must have unlocked the door to make it easier to get into. The DON stated he would ensure the room stayed locked.",2020-09-01
2926,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2019-12-04,695,D,0,1,KNB211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide oxygen therapy in accordance with professional standards and practices. The failed practice had the potential to affect 1 of 5 residents receiving oxygen therapy. Resident identifier: Resident #14. Census: 71 Findings included: a) Resident #14 A review of the policy, Oxygen Concentrator, revision date: 12/01/18. showed when oxygen was to be administered, the oxygen flow rate would be set in accordance with the physician's orders [REDACTED].>An observation, on 12/02/19 at 10:55 AM, revealed Resident #14 was receiving oxygen (O2) via nasal cannula at 4 liters per minute. An additional observation, on 12/03/19 at 08:00 AM revealed Resident #14 was receiving O2 at 4L/min via nasal cannula. An interview with the Director of Nursing (DON), on 12/03/19 at 08:00 AM verified the O2 flow rate to be at 4L/min but should have been set at 3 L/min. A review of the physician's orders [REDACTED].#14 was to receive O2 at 3L/min per nasal cannula continuous.",2020-09-01
2927,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2019-12-04,726,E,0,1,KNB211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Care and services were not provided to prevent possible aspiration of fluids, medication administration monitoring, prevention of pressure ulcers, infection control during medication administration, and ensuring fall interventions were in place. These practices had the potential to affect more than a limited number residents failed practice affected in the facility. Resident identifiers: #413, #3, #21, #47, and #12. Facility census: 71. Findings included: a) Resident 413-Medication Administration A policy review titled, NSG305 Medication: Administration: General with revision date 11/01/19, was reviewed on 12/04/19. The policy stated, Remain with patient until administration is complete. Do not leave medications at the patient's bedside. An interview with the Resident, on 12/02/19 at 11:00 AM, revealed the nurses leave medications at the bedside table for self-administration on most days. An observation at the time of the interview, on 12/02/19 at 11:00 AM, revealed an empty plastic medication cup on bedside table in front of the Resident. An interview with Speech Therapist (ST) #70, on 12/03/19 at 8:40 AM, revealed a modified [MEDICATION NAME] swallow test had been completed on the Resident on 10/24/19. The test was completed because of the resident's history of aspiration and swallowing issues. The ST stated the test showed decreased laryngeal elevation and incomplete laryngeal vestibular closure. The Resident is a 2 on the Aspiration Scale meaning thin liquids do enter the airway. A record review, on 12/03/19, at 9:00 AM, revealed no self-administration of medications on the Physician Orders, Kardex, or Care Plan. Further observation, on 12/03/19 at 9:20 AM, revealed Resident #413 was self-administering his own medications. The nurse was not in the room at the time of the observation. An interview with the Resident at the time of the observation, on 12/03/19 at 9:20 AM, revealed the nurse left my medications for me to take. Continued observation, on 12/03/19 at 9:21 AM, revealed Licensed Practical Nurse (LPN) #11 walked into the Resident's room. LPN #11 was interviewed and asked if the Resident self-administered his own medication. The LPN replied, Yes, I check back periodically to make sure he took them all. An Interview with Director of Nursing (DON), on 12/03/19 at 10:55 AM, confirmed Resident #413 does not have a physician order [REDACTED]. An interview with LPN #11, on 12/03/19 at 11:10 AM, confirmed the list of medications that were given to the Resident at 9:00 AM. LPN #11 confirmed the following medications were self- administered. -Aspirin 81 mg -Duloxetine [MEDICATION NAME] Capsule delayed release 60 milligrams (mg) -[MEDICATION NAME] 5 mg [MEDICAL CONDITION] Do not handle med if pregnant or may become pregnant -[MEDICATION NAME] 25 mg give 0.5 tablet 2X [MEDICAL CONDITION] to 125 mg -Tylenol 500 mg -Vitamin D3 400 units -[MEDICATION NAME] 25-100 mg II A list of residents who wander in the facility was provided by the DON. The following residents were at risk of of having access to any medications left in resident rooms by nurses: Resident #10 Resident #363 Resident #64 Resident #6 b) Resident #3-Aspiration Risk A record review, on 12/03/19 at 2:20 PM, revealed a [DIAGNOSES REDACTED]. The Resident lacked capacity. A physician order [REDACTED]. The Care Plan stated, Provide diet as ordered/tolerated- Regular/liberalized Dysphasia advance. 2 handle sip cup w/ lid, no straws. Resident #3 lacks capacity. A Nutritional Assessment, completed on 12/03/19, stated, Diet order: dysphasia advance Intakes excellent x lookback- 100% Food snacks BID b/t meals House supplement ordered TID- consuming 75-100% per [DATE] handle sip cup w/ lid, no straws Fluids encouraged per staff . An observation of the Resident's room, on 12/03/19 at 2:35 PM, revealed an 18-ounce water bottle with a straw that sat on the bedside table over the Resident's bed. The water bottle had 10 ounces of water in it. A four (4) ounce Vanilla Shake Supplement with Resident's name label on the carton was also on the bedside table. The Vanilla Shake Supplement was open with a straw in the carton. The Vanilla Shake Supplement was observed to be half empty. Both containers of fluid were easily accessible to Resident #3. A two handled sip cup was not observed to be available in the room at the time of the observation. An interview and observation with the Administrator, on 12/03/19 at 2:55 PM, in the Resident's room, confirmed there were straws in the Resident's water bottle and supplement on the Resident's bedside table. The Administrator immediately removed the water bottle and the half empty Vanilla Shake Supplement carton with straw from the resident's room. The Administrator stated the straws should not have been available for the Resident. The Administrator stated the Nurses Aides pass the water and supplements out to residents and would have provided the straws. c) Resident #413-Aspiration Risk An interview with the Resident, on 12/02/19 at 11:00 AM, revealed I am not supposed to have straws the speech therapist said don't drink out of straws because of trouble swallowing and aspiration. The Resident stated, the staff continues to bring me straws after I have voiced many concerns to them about not being allowed to have them. An observation of the Resident's Room, on 12/02/19 at 11 AM, revealed two (2) straws on the bedside table. One (1) straw was lying on the bedside table and the other straw was in the provided water bottle. The Resident demonstrated what happened when he drank from a straw which resulted in a coughing episode. Another interview with the Resident, on 12/03/19 at 8:20 AM, revealed the Resident was provided a straw for fluid intake. The Resident stated, I was given a straw again. Further observation of the Resident's Room, on 12/03/19 at 8:20 AM, revealed a straw in the Resident's water pitcher. A dietary tray slip with the Resident's name on it was on the bedside table. The dietary slip was immediately reviewed and stated, NO STRAWS. An interview with Speech Therapist (ST) #70, on 12/03/19 at 8:40 AM, revealed a modified [MEDICATION NAME] swallow test had been completed on the Resident on 10/24/19. The test was completed because of the resident's history of aspiration and swallowing issues. The ST stated the test showed decreased laryngeal elevation and incomplete laryngeal vestibular closure. The Resident is a 2 on the Aspiration Scale meaning thin liquids do enter the airway. The speech therapist confirmed a physician's orders [REDACTED]. A medical record review, on 12/03/19 at 9:05 AM, revealed the Resident's Kardex and Care Plan did not include the order for no straw use which was dated for 10/28/19. The Resident scored a 13 on the Brief Interview for Mental Status (BIMS) Assessment demonstrating little to no cognitive impairment. The Resident also had a [DIAGNOSES REDACTED]. An interview with Registered Nurse (RN) #18, on 12/03/19 at 9:16 AM, revealed the Kardex is the main communication tool concerning patient care for all Nurse Aides. An interview with the Dietary Manager (DM), on 12/03/19 at 9:18 AM, revealed a diet order was provided to her in (MONTH) of 2019 for the Resident not to have straws. The DM then stated the order was communicated daily and with each meal on a Diet Tray Ticket which included the words NO STRAWS. An interview with Nurse Aide (NA) #105, on 12/03/19 at 9:24 AM, revealed she was the aide caring for the Resident. When asked about the Resident's straw restriction the NA stated, I have no idea if he is allowed to have straws or not. The NA further stated, I will have to check with the nurse. An interview with Licensed Practical Nurse (LPN) #11, on 12/03/19 at 9:25 AM, revealed Resident #413 does have a physician's orders [REDACTED]. The LPN stated he should not have straws, but it is no big deal if he does. She then further stated he is a grown man and can make his own decisions. The LPN stated the straw restriction was not on the current care plan would expect to see the straw restriction included. An interview with Director of Nursing (DON), on 12/03/19 at 10:55 AM, stated he was unaware of the Resident's physician order [REDACTED]. d) Resident #21-Pressure Ulcer Prevention A record review revealed the resident was admitted to the facility on [DATE] with pressure ulcers to both the left and right heels. Both areas were staged as DTI's (deep tissue injuries). Review of a skin integrity report revealed both areas healed on 02/26/19. A review of the current care plan, revealed an intervention to off load/float heels while in bed, initiated on 02/11/19 to prevent new skin breakdown. An observation of the resident with the Director Of Nursing (DON) at 7:32 AM on 12/03/19, found the resident was in bed. Both heels were resting on the mattress. No device was present to off load/ float the heels. The DON confirmed the residents heels should be floated and directed nursing staff to take care of this issue. e) Resident #47-Infection Control with Medication Administration An observation, on 12/03/19 at 8:30 AM, revealed Licensed Practical Nurse (LPN) #58 was administering an injection of insulin to Resident #47. The LPN did not wash or sanitize their hands before the administration. The LPN also did not apply gloves to give the injection. The LPN left the Resident's room and returned to the hallway and medication cart without sanitizing their hands. An interview with LPN #58, on 12/03/19 at 8:35 AM, revealed he forgot to wash his hands and apply gloves. The LPN stated he became nervous and totally forgot. f) Resident #12-Fall Mat An observation, on 12/02/19 at 02:03 PM, revealed Resident #12 was in bed and had bilateral floor mats on the floor beside the bed. The mat on the resident's left side slid when stepped on. This was verified with an interview with Nurse Aide (NA) #35 at this time. An interview with NA #35, on 12/03/19 at 09:27 AM, revealed yesterday on 12/02/19 the fall mat was also sliding and stated it had been placed on the floor incorrectly. NA#35 stated I should have known better. A record review noted the comprehensive care plan addressed poor safety awareness and noted the resident is to have bilateral floor mats. An observation of the Resident, on 12/03/19 at 07:37 AM, revealed the Resident was in bed with the fall mat propped up against the wall and not on the floor as ordered. An interview with the DON, on 12/03/19 at 07:55 AM, verified the fall mat was not in place as ordered.",2020-09-01
2928,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2019-12-04,761,D,0,1,KNB211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure drugs and biological's used in the facility were stored and labeled in accordance with currently accepted professional principles. Opened medications stored in the 100 Hall Medication Cart and the Medication Storage Room were unlabeled and undated. A medication stored in the Medication Room was expired. These practices had the potential to affect a limited number of residents. Facility census: 71. Findings include: a) 100 Hall Medication Cart An observation of the 100 Hall Medication Cart, on [DATE] at 11:15 AM, revealed the following medication was opened but not labeled or dated as to when: One (1) bottle of Milk of Magnesia An interview with Registered Nurse (RN) #24, on [DATE] at 11:16 AM, revealed all opened medications should be dated with the date they were opened and who opened them. b) Medication Storage Room An observation of the Medication Storage Room, on [DATE] at 11:20 AM, revealed the following medications were opened but not labeled/dated or expired: One (1) bottle of Iron Supplement with an expiration date of ,[DATE] One (1) bottle of [MEDICATION NAME] Protein Derivative opened and not labeled or dated as to when An interview with RN #24, on [DATE] at 11:22 AM, revealed everything is to be labeled and dated when opened. The RN stated no medications should be expired.",2020-09-01
2929,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2019-12-04,791,D,0,1,KNB211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to ensure one (1) of two (2) residents reviewed for the care area of dental services received timely routine dental services. Resident identifier: #50. Facility census: 71. Findings include: a) Resident #50 On 12/02/19 at 10:59 AM, the resident said, I need my teeth cleaned. The resident said she had most of her natural teeth. The resident said she had been out for one cleaning after she came to the facility, but she believed, It was time to go again, I want to keep my teeth if I can. The resident was admitted to the facility on [DATE]. Record review found the resident's most recent minimum data set (MDS), a quarterly, with an assessment reference date (ARD) of 11/03/19, found the resident scored a 14 on the brief interview for mental status (BIMS.) A score of 14 indicates the resident is cognitively intact. Medical record review found a dental consult dated 08/14/18, Pt. (patient) presented w/ (with) plaque calculus build up and a deep cleaning w/ curettage was completed today. (Curettage is a surgical procedure designed to remove the soft tissue lining of the periodontal pocket with a cruet, leaving only a gingival connective tissue lining.) The dentist's [DIAGNOSES REDACTED]. The dentist recommended a follow up appointment, A deep cleaning with curettage needs to be repeated in 6 months. At 2:07 PM on 12/03/19, Registered Nurse (RN) #54 was unable to find evidence another appointment scheduled with the dentist. On 12/03/19 at 2:53 PM, RN #105, said the resident had an appointment scheduled for 02/05/19 but the schedule book said the resident canceled the appointment. I don't know why. RN #105 said she would do some investigation into the situation. The schedule book was a spiral monthly calendar, consisting of handwritten notations, which are not part of the resident's medical record. At approximately 4:20 PM on 12/03/19, RN #105 provided the following information: A nursing note dated 08/16/18, which read: New orders for F/U visit with (Name of dentist) on 02/15/19 at 11:00 AM. Resident alert and oriented. Notified of appointment with no questions at this time. A copy of a physician's orders [REDACTED]. A copy of a social service note, written on 12/03/19 at 4:08 PM (after surveyor intervention). SW (social worker) spoke with (Name of resident) regarding dental consult 02/05/19. (Name of Resident) stated she canceled that appt. (appointment.) SW offered to make her an appt. (Name of resident) stated she would think about it and speak with her daughter and SW know. She does not report any pain or difficulty chewing at this time. On 12/04/19 at 8:53 AM, the Director of Nursing (DON) said the resident canceled the appointment. When we ask her, do you want it rescheduled, she had to check with daughter about the money. The DON was unable to provide evidence of the above. (The resident receives Medicaid assistance; therefore, the facility would be responsible for payment.) At the close of the survey on 12/04/19 at 12:15 PM, no further information from the resident's medical record was presented to determine why the appointment was discontinued or if any other attempts were made to schedule a new appointment prior to surveyor intervention on 12/03/19.",2020-09-01
2930,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2019-12-04,880,D,0,1,KNB211,"Based on observation and interview, the facility failed to provide a safe and sanitary environment that prevented the development and transmission of communicable diseases and infections. A nurse administering an injection to a resident failed to wash their hands before and after and apply gloves while performing the administration. This practice had the potential to affect a limited number of residents. Resident identifier: #47 Facility census: 71. Findings include: a) Observation An observation, on 12/03/19 at 8:30 AM, revealed Licensed Practical Nurse (LPN) #58 was administering an injection of insulin to Resident #47. The LPN did not wash or sanitize their hands before the administration. The LPN also did not apply gloves to give the injection. The LPN left the Resident's room and returned to the hallway and medication cart without sanitizing their hands. b) Interview An interview with LPN #58, on 12/03/19 at 8:35 AM, revealed he forgot to wash his hands and apply gloves. The LPN stated he became nervous and totally forgot.",2020-09-01
2931,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2019-12-04,919,D,0,1,KNB211,"Based on observation and interview, the facilty failed to ensure the call lights for all residents are in working order. This deficient practice was observed for 1 of 21 residents in the sample. This failed practice had the potential to affect a limited number of residents. Resident identifier: #12. Facility census: 71 Findings included: a) Resident #12 During an interview on 12/02/19 at 01:59 PM, Resident #12 was observed to have the call light in hand pushing the button. Resident #12 stated she was having trouble with her light not being answered. At this time, surveyor observed the light not activating when pushed and the light was confirmed to be not working properly by NA #35. On 12/02/19 at 02:07 PM, an interview with the Maintenance Supervisor confirmed the call light was not working and would have to be replaced.",2020-09-01
4021,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2017-03-09,205,D,1,0,U91Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to provide notification of bed hold policy at time of hospital transfer for two (2) of six (6) sampled residents. Resident identifier: #3 and #4. Facility census: 70. a) Resident #3 Review of the minimum data set (MDS) revealed Resident #3 was discharged out of the facility to the hospital on [DATE], and 02/04/17 with return to the facility anticipated for both discharges. No bed hold documentation was presented by the facility. b) Resident #4 Review of the MDS revealed Resident #4, was discharged out of the facility to the hospital on [DATE], 12/05/16 and 12/28/16, with return to the facility anticipated on all three discharges. No bed hold documentation was presented by the facility. On 03/08/17 at 11:34 a.m., the facility administrator stated the facility verbally notified Resident #3 and #4 and/or their medical power of attorney, but, at the time of discharge, did not completed the bed-hold documentation. The administrator went on to explain the facility recognized a failure to complete required bed-hold documentation and as of 01/01/17 put in place the requirement to complete documentation of the bed hold notice of policy & authorization form.",2020-03-01
4257,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-10-07,160,E,0,1,310011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to dispense funds timely from trust accounts for two (2) of three (3) deceased residents reviewed. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #69 and #166. Facility census: 69. Findings include: a) Resident #69 On [DATE] at 4:40 p.m., an interview was completed with the facility Bookkeeper #9 regarding the conveyance of residents' funds upon their death. Bookkeeper #9 stated, If they (residents) have an account and they die, we have so many days to turn the money over to unclaimed property or to have someone show they are executor of the estate. I think it's 30 days. Bookeeper #9 further stated Resident #69 passed away on [DATE], the facility closed the account on [DATE] and the check was sent out on [DATE]. Review of the Resident Statement for Resident #69 revealed Resident #69 died on [DATE] and the check to close her trust fund account was issued on [DATE]. b) Resident #166 Review of the Resident Statement for Resident #166 revealed Resident #166 died on [DATE]. The form noted a check to close out the trust fund account was issued on [DATE]. c) Interview with Business Office Manager On [DATE] at 9:18 a.m., an interview was completed with the Business Office Manager (BOM) who stated, We hold the checks for 30 days to let the family decide if they want to open an estate. After that, we send the check to the estate or if it is unclaimed property, we send it to our office in New Mexico. Then they send it to the State's unclaimed property.",2020-02-01
4258,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-10-07,174,E,0,1,310011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews and record reviews, the facility failed to encourage residents to create a homelike environment and failed to attempt to locate reported missing resident personal property. This affected two (#31 and #6) of 3 residents reviewed for personal property out of a Stage 2 sample of 30. Findings include: 1. During an interview on 10/03/16 at 1:52 PM, Resident #31 stated she had not been encouraged by staff to bring in any personal items to make her room more homelike. Review of the clinical record of Resident #31 on 10/05/16 revealed the resident was admitted to the facility on [DATE]. During interview on 10/05/16 at 12:45 PM, Registered Nurse (RN) #40 stated she was a supervisor and she worked with many residents to complete admission assessments. RN #40 stated Residents get oriented to their room by the nurse. We tell them things they should bring in, like necessities, like shoes and clothes. We don't have anything that encourages them to bring in things that make it a personal environment. During interview on 10/06/16 at 8:55 AM, the Guest Services Director (GSD) stated I have an interview process for new admissions. We see how the transition was, let them know about activities and meals. It's really an orientation. If I have family members present, I tell them they are welcome to bring in personal items. The rooms have a locking drawer. We tell them what things they can bring in. Based on staff interview, resident interview and record review, the facility failed to encourage residents to create a homelike environment and failed to attempt to locate reported missing personal property for two (2) out of three (3) residents reviewed for personal property. This failed practice had the potential to affect for than a limited number of people. Resident identifiers: #31 and #6. Facility census: 69. Findings include: a) Resident #31 During an interview on 10/03/16 at 1:52 p.m., Resident #31 stated she had not been encouraged by staff to bring in any personal items to make her room more homelike. Review of the clinical record for Resident #31 revealed the resident was admitted to the facility nearly 8 months ago. During interview on 10/05/16 at 12:45 p.m., Registered Nurse (RN) #40 stated she was a supervisor and she worked with many residents to complete admission assessments. RN #40 stated, Residents get oriented to their room by the nurse. We tell them things they should bring in, like necessities, like shoes and clothes. We don't have anything that encourages them to bring in things that make it a personal environment. During interview on 10/06/16 at 8:55 a.m., the Guest Services Director (GSD) stated, I have an interview process for new admissions. We see how the transition was, let them know about activities and meals. It's really an orientation. If I have family members present, I tell them they are welcome to bring in personal items. The rooms have a locking drawer. We tell them what things they can bring in. b) Resident #6 During interview on 10/04/16 at 11:15 a.m., the family member of Resident #6 stated the resident had a quilt with two matching pillow shams for her bed and sometime in late (MONTH) or early (MONTH) (YEAR) one of the shams disappeared. The family member stated facility staff had been told about the missing sham in late (MONTH) or early (MONTH) but the sham had not been located nor had there been a status report on the facility's search for the item. During an interview on 10/05/16 at 10:00 a.m., Social Worker (SW) #31 stated missing items should be reported to social service staff and then social services staff would complete a Grievance/Concern Form. SW #31 stated dates are recorded for each concern and the resolution date established. SW #31 further stated she did not currently have a Grievance/Concern Form identifying the missing sham for Resident #6. On 10/06/16 at 10:20 a.m., nurse aide (NA) #61, identified by the family as who they reported the missing sham to, was interviewed. NA #61 stated she recalled the family member had told her about the missing sham on a weekend just a little over a month ago but she could not recall the exact date. NA #61 stated she reported the missing item to facility laundry aide #28. Laundry aide #28 was unavailable for interview during the days of the recertification survey. An interview was conducted with the facility Administrator on 10/06/16 at 10:50 a.m. to clarify the facility policy regarding searches for missing resident possessions, particularly on the weekends. The Administrator stated if staff received a report of a missing item and it was not immediately located, staff have four options of whom to inform so that a more in-depth search may be initiated and the missing item can be logged into the reporting system. The four reporting options are: 1) guest services; 2) weekend manager; 3) social services; or, 4) the nurse manager on duty. The Administrator confirmed that until the concern of the missing sham was raised during the annual recertification survey on 10/05/16, no search had been initiated.",2020-02-01
4259,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-10-07,223,E,0,1,310011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure residents were protected from incidents of repeated inappropriate sexual contact and language displayed by a cognitively impaired resident. This involved discharged and current male residents, and had the potential to affect more than a limited number of residents in the facility. Resident identifiers: #103 and #146. Facility census: 69. Findings include: Review of the clinical record of Resident #103 revealed the resident was originally admitted to the facility in (MONTH) 2014 and had the following Diagnoses: [REDACTED]. During interview on 10/05/16 at 9:27 a.m., the Administrator and DON revealed five (5) incidents of sexually inappropriate behavior by Resident #103 towards other residents: --On 10/29/15, Resident #103 was witnessed by staff putting his hand in the pants of a cognitively impaired resident. --On 11/12/15, Resident #103 was involved in an incident of resident to resident inappropriate physical contact with a now discharged resident. Resident #103 was reported to have rubbed the resident's leg toward the resident's groin area. --On 01/28/16, Resident #103 was involved in an incident of resident to resident physical contact with an alert and oriented resident who is now discharged . During that incident Resident #103 was noted rubbing the back of the resident's neck. --On 09/18/16, Resident #103's roommate reported the resident was playing with his toes and attempt to get into bed with him. --On 09/29/16, Resident #103 kissed the back of another resident's hand, stroked his beard and asked him to come to his room later for a kiss. During an interview, on 10/04/16 at 4:10 p.m., Nurse Aides (NA) #66 and #82 revealed they monitored Resident #103 for any inappropriate behavior. The NA's stated they were to immediately intervene if they witnessed any inappropriate behavior and report it to the charge nurse. Review of the record revealed Resident #103 had a current care plan dated 09/30/16, related to him exhibiting sexual inappropriateness. The care plan included the goal for the resident not to exhibit any acts of sexually inappropriate behavior. Care plan interventions included: --to allow the resident time to vent feelings/needs; --approach resident in a calm friendly manner; --document interventions and resident's response; --encourage family involvement; --encourage resident to attend activities of choice; --adjust time spent in activities to resident's tolerance and attention span; --identify behavior triggers and reduce exposure to triggers; --observe and document the resident's activity and whereabouts every 30 minutes; and --obtain psychological evaluation as ordered. The resident also had a current care plan initiated on 09/30/16 and revised on 10/03/16 related to exhibiting or having the potential to demonstrate verbal behaviors related to cognitive loss/dementia, poor impulse control and psychiatric disorder(s). The care plan goals stated the resident would demonstrate effective coping skills related to verbal behavior by next review; resident would not exhibit verbal outbursts direct toward others by next review and resident would verbalize understanding of triggers that result in poor impulse control and effective coping mechanisms. The care plan interventions included to: --Monitor medications, especially new/changed/discontinued, for side effects and resident's/patient's response contributing to verbal behaviors, including: antipsychotics, [MEDICATION NAME], opioids, benzodiazepines (recent discontinuation, omission or decrease in dose) drug interactions, adverse drug reactions, drug toxicity, or errors. --Evaluate the nature and circumstances (i.e., triggers) of the (resistive behavior) with resident/patient and family members/caregivers, e.g., provoked/not provoked, offensive, defensive, purposeful, during specific activities, involvement of others, patterned, easily startled, etc. --Discuss findings with resident/patient and family members/caregivers and adjust care delivery appropriately. --Evaluate need for Psych/Behavioral Health consult. --Refer resident to Psych/Behavioral Health provider to develop a Behavior Contract, if appropriate. --Provide all effective interventions (e.g., non-pharmacologic, pharmacologic) for behaviors and/or psychiatric disorder(s), (remove resident from environment) to assist resident/patient in controlling physical behaviors. --Encourage resident to seek staff support for distressed mood. --Approach the resident in a calm, unhurried manner; reassure as needed. --Remove resident from environment, if needed. --Gently guide the resident from the environment while speaking in a calm, reassuring voice. --Listen to resident and try to calm. Review of the following Minimum Data Set (MDS) assessments indicated Resident #103 was independent with transfers, and was non-ambulatory and mobile in his room and on the unit using a wheelchair: --Significant change MDS with an assessment reference date (ARD) of 09/26/16; --Quarterly MDS with an ARD of 08/11/16, 05/12/16, 08/20/15, and 05/20/15; and --Annual MDS with an ARD of 02/12/16. The Administrator and DON verified Resident #103 had a history of [REDACTED]. The Administrator confirmed the incidents of inappropriate resident to resident physical contact were not reported to the State agency. During an interview on 10/05/16 at 11:33 a.m., Social Worker (SW) #31 stated she was working on 09/18/16 when she was informed by a Nurse Aide (NA) (she did not recall name) that Resident #103's roommate (Resident #146) reported Resident #103 had touched his toes and attempted to get in his bed. SW #31 stated she went and spoke with Resident #146 who verified the allegation. She stated Resident #146 was not upset and did not express fear of Resident #103. Resident #146 stated they had been friends for a long time and he did not feel it was a big deal. SW #31 stated she notified the Administrator immediately of the incident due to Resident #103 allegedly attempting to get into Resident #146's bed. SW #31 stated Resident #103 was moved to another room with an alert and oriented resident. Review of General Notes by Registered Nurse (RN) #40 dated 10/29/15 at 9:35 a.m., revealed after exiting Resident #103's room, RN #40 observed Resident #103 reaching in the front of another resident's pants. The notes documented RN #40 asked Resident #103 what he was doing and Resident #103 pulled his hands out of the other resident's pants, looked at RN #40 and said What? The notes documented RN #40 re-directed the resident to his room and advised him to keep his hands off of other residents. The notes documented RN #40 assisted the other resident to nursing station and advised the physician of Resident #103's behavior. Review of General Notes, dated 11/12/15 at 3:39 p.m., revealed RN #40 interviewed Resident #103's former roommate (now discharged ) as she had been advised by a staff member Resident #103 may have had inappropriate sexual contact or conversation without the former roommates consent. The notes documented Resident #103's former roommate stated about a month after he became roommates with Resident #103 he was asked by Resident #103 how big his penis was. The notes documented Resident #103 proceeded to advise his former roommate he had oral copulation with 12 to 15 men in his lifetime. The former roommate also stated that around this time he was scheduled to have a colonoscopy procedure. It was during this time, he was awakened one night by Resident #103 rubbing his bare leg and advancing toward his groin. The former roommate told Resident #103 to stop to which Resident #103 replied, But, I love you. The notes further documented the former roommate reported he told Resident #103 to stop and go away again and Resident #103 returned to his side of the room. Per the notes, the former roommate went on to report on another night around the same time he was awakened again by Resident #103 rubbing his feet. He told Resident #103 to stop and Resident #103 started kissing his former roommate's feet. The former roommate told Resident #103 to stop or he would tell the administrator and Resident #103 returned to his side of the room. The notes documented Resident #103 had not touched his former roommate since that incident. The notes further documented the former roommate stated he noticed daily when Resident #103 exited their bathroom he watched his former roommate through the cracked hinged part of the bathroom door. The former roommate stated he tried to keep his curtain pulled so that Resident #103 could not see him when he exited the bathroom. The notes documented RN #40 notified the physician, the Director of Nursing and administrator of her interview results. The notes documented Resident #103 was moved to a private room, multiple laboratory test were ordered, a geriatric psychiatry consultation and the psychologist had also been requested for consult. Review of Social Service Notes dated 11/13/15 at 12:58 p.m. revealed the Administrator, Director of Nursing (DON) and Social Worker met with Resident #103's medical power or attorney (MPOA) that same day. The notes documented the meeting was to discuss Resident #103's recent behavior which led to him being moved to a private room to protect his former roommate and also to protect Resident #103 from possible negative reactions from other resident's toward him. It was discussed the resident was scheduled to see the psychologist that weekend and he would be asked to explore with the resident the extent to which he understood why he is in a different room and make an effort to counsel the resident in regards to his behavior and to gather his recommendations for medication, ongoing counseling and possible inpatient placement. The notes documented the resident's family member advised Resident #103 now verbalized and demonstrated affection toward her (hugs, kisses, etc.) which was in stark contrast to the majority of his life. The DON advised that Resident #103 requested that morning to not have male aides work with him. Review of a Report of Consultation by the psychologist, dated 11/14/15, revealed the consult documented Resident #103 had a significant increase in sexual behaviors towards male residents. Review of a Psychiatric Consultation Log indicated an interview was conducted with Resident #103 on 11/16/15 due to the resident being referred for inappropriate behaviors of touching male residents and male staff. The Consultation findings documented Resident #103 asked if he was in trouble and if he was even capable. The findings documented Resident #103 had capacity to make medical decisions and that he denied inappropriate behaviors. The documentation revealed Resident #103 stated he is a Christian and at his church people shake hands and pat each other on the shoulder. He stated he was just joking and people took the behaviors the wrong way stating, I was just kidding them. They did not take it that way. I think that is why I am here. Review of a Report of Consultation by the psychologist, dated 11/24/15, revealed the resident was seen for a follow-up and he did not have capacity since 11/25/14. The psychologist documented he had seen the resident on several occasions and that he had a recent inappropriate sexual behavior incident that was uncharacteristic of him. The psychologist documented Resident #103 did not appear to recall his behavior and that his [MEDICATION NAME] was increased on 11/12/15 with appears to have had positive results. Review of General Notes, dated 01/14/16 at 9:45 p.m., found at approximately 7:15 p.m. Resident #103 was propelling in his wheelchair down the 200 hallway towards another resident's room (resident now discharged ) when he attempted to open the other resident's door. The notes documented the nurse interfered and informed Resident #103 he could not go into that room, that if the other resident wanted a visitor then he would seek him out. The notes documented Resident #103 got angry and stated the other resident had invited him to his room at dinner time. The nurse again stated to Resident #103 if the other resident wanted a visitor he would come seek him. Resident #103 appeared very agitated and yelled, Who are you?! and, Are you the boss?! The notes documented the nurse re-educated Resident #103 again that he was not allowed in the room and he finally went back to his own room. General Notes, dated 01/15/16 at 2:56 p.m., documented Resident #103 again attempted twice to go in the other resident's room (same now discharged resident) by attempting to open the door to room. The notes documented Resident #103 was instructed to please go to his room or another area of the facility. The notes documented Resident #103 stated he was invited to the other resident's room. The notes document the other resident was interviewed and stated no invitation was made. The notes documented Resident #103 stated he was tired of you people treating me like dirt, but he complied and went back to his room. General notes indicated staff were to continue to monitor and re-educate the resident as necessary. General Notes, dated 01/15/16 at 5:15 p.m., documented Resident #103 was found in the other resident's room (same now discharged resident) by a N[NAME] The notes documented Resident #103 was asking the other resident for his address. The NA then asked the other resident if he wanted Resident #103 to have his address to which the other resident stated no. The notes documented the NA then tried to redirect Resident #103 out of the resident's room and Resident #103 told the NA, Leave me alone you [***] ! and as the NA was escorting Resident #103 out of the room he swung and tried to hit her. The notes documented the nurse and nursing supervisor tried to talk to Resident #103 and redirect and Resident #103 stated, You are a[***]y supervisor! The notes documented Resident #103 was redirected to his room shouting, I will have your jobs! The physician was notified and ordered an antipsychotic medication ([MEDICATION NAME] 5 mg) intramuscularly once at that time for combative behavior and agitation. Review on 10/05/16 revealed a General Late Entry Notes, dated 01/28/16 at 3:40 p.m., documented Resident #103 was following another male resident to his room and was asked and re-directed to his room on another hall. The note documented, less than 5 minutes later, Resident #103 went into another resident's room in his wheelchair and the nurse was observing. The notes documented Resident #103 was gently rubbing the back and neck of the resident in the room and the resident stated. No, no, no, and was trying to get away from Resident #103. The nurse then removed Resident #103 from that room and hall, and re-directed him to the hall he resided on. The notes documented Resident #103 raised his voice yelling, Don ' t tell me what I can and don ' t tell me what I can and can ' t do! The incident was reported to the DON. Review of General Notes, dated 01/29/16 at 2:26 p.m., revealed Resident #103 followed another male resident around the facility and wanted to know if he could be roommates with that resident. The notes stated Resident #103 wanted to know if he could go to his room with him. The notes stated Resident #103 was re-directed four times that shift. Review of General Notes, dated 01/29/16 at 2:52 p.m., revealed Resident #103 was sticking his finger down his throat and gagging in hallway and when asked if he was okay, Resident #103 stated, Yeah can I go to his room now? The notes stated Resident #103 was referring to another male resident (noted in the General Notes on 01/29/16 at 2:26 p.m.) and Resident #103 was redirected. Review of the Physician Determination of Capacity, dated 05/10/16, revealed Resident #103 was assessed to lack sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. The document indicated the [DIAGNOSES REDACTED]. The nature of the incapacitation was indicated as evidenced by cognitive loss, inappropriate answers to questions and inability to understand or make medical decisions. The expected duration of the resident's incapacity was indicated as long term. Review of General Notes, dated 06/01/16 at 2:54 p.m., revealed orders were written for Resident #103 to have a consultation with the psychiatrist due to predatory behavior. A Report of Consultation, dated 06/3/16, documented the psychologist saw Resident #103 on several occasions due to similar concerns, most recent 12/22/15. The psychologist documented inappropriate sexual behavior (ISB) is not uncommon with dementia. Resident made inappropriate comments to residents. Review of General Notes by Social Worker #31, dated 09/18/16 at 3:08 p.m., revealed she was approached by a NA who stated Resident #103's roommate alleged Resident #103 was inappropriate with him. SW #31 documented she interviewed Resident #103's roommate who stated Resident #103 played with his toes and attempted to get in bed with him. The roommate indicated Resident #103 had displayed inappropriate behaviors. Review of the licensed social worker's psychiatric consultation log revealed Resident #103 was referred due to sexually inappropriate behaviors and was interviewed on 09/20/16. The consultation findings revealed Resident #103 was having sexually inappropriate behaviors and was moved to another room. The documentation stated Resident #103's new roommate was oriented and Resident #103 sleeps most of the day and is then up and out at night. He was reported by a peer that he touched him. Per staff report Resident #103 stated this did occur. Review of another psychiatric consultation log by the licensed social worker (LSW) from the local hospital behavioral department also with an interview date of 09/20/16, revealed the findings of the interview documented Resident #103 stated he was sorry. He stated it would not happen again. He stated it is, over with and that his roommate is not his type. He stated that it had not happened before. LSW documented it was charted he had past events. The LSW documented in the findings Resident #103 stated he could control his feelings. Review of a Physician Determination of Capacity form, dated 09/27/16, revealed the psychologist certified the Resident #103 lacked sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. The documentation indicated the nature of the incapacity was evidenced by cognitive loss, inappropriate answers to questions and inability to understand or make medical decisions. The expected duration of the incapacity was indicated as long term. Review of Care Plan Evaluation Notes, dated 09/28/16 at 9:06 a.m., revealed a significant change assessment was completed for Resident #103 for behaviors of sexual inappropriateness with previous roommate and nursing staff since last review on 08/11/16. Review of Social Service Late Entry Notes, dated 09/29/16 at 2:26 p.m., revealed SW #31 was told Resident #103 had made inappropriate advances to another resident. SW #31 interviewed the other resident who stated Resident #103 kissed the back of his hand, stroked his beard and asked him to come to his room later for a kiss. The other resident stated he didn't feel violated. SW #31 documented she brought Resident #112 to her office to discuss this allegation and while pushing the resident's wheelchair to the front of the facility Resident #103 asked this same male resident to come see him in his room. Resident #103 told the other male resident he had the room to himself and was lonely. The other resident told him he wasn't interested. SW #31 documented that within minutes Resident #103 asked the same resident again to come see him in his room. SW #31 and the DON spoke with Resident #103 regarding these allegations. SW #31 documented Resident #103 did not deny or admit to the allegations. SW #31 documented they explained to Resident #103 his behavior wasn't appropriate and advised him to refrain from touching and propositioning other residents. Review of General Notes, dated 09/29/16 at 6:30 p.m., revealed Resident #103 was noted to be alone in his room with his roommate while his daughters were present in facility but visiting another resident in their room at that time. The notes documented Resident #103 was noted to be holding/patting his roommate's left hand and his roommate told him to, go visit with your daughters and repeatedly told Resident #103, thank you, ok, goodbye. The notes documented Resident #103's due to a medical condition the roommate was unable to remove his left hand from Resident #103's reach. The notes documented Resident #103 was redirected to the restorative dining room with both his daughters. The DON and administrator notified at that time with recommendations to move Resident #103 to another room. According to facility documentation of Resident #103's activity and whereabouts on 09/29/16, Resident #103 was in the dining room with family at 6:00 p.m., in his room alone holding his roommate's hand at 6:15 p.m. and in the restorative dining room with family at 6:30 p.m. There was no evidence the resident's level of supervision was increased beyond the every 30 minute checks after he was again noted displaying unwanted resident to resident physical contact. Review of General Notes, dated 09/29/16 at 6:45 p.m., revealed RN #40 spoke with Resident #103's family inquiring if they were aware of Resident #103's behavior that day related to him being inappropriate with two alert and oriented residents. The notes stated that during this meeting a nurse came to staff and the family that Resident #103 was asking his roommate at that very moment about the size of his penis. Review of General Notes, dated 09/29/16 at 7:20 p.m., revealed Resident #103's roommate reported to a NA that Resident #103 asked him, how big is his penis and if, he could see it. The note revealed the roommate was interviewed at that time and he reported, (Resident #103's name) always asks me how big ' it ' is and if he can see it. Review of the Change in Condition Notes, dated 09/29/16 at 11:04 p.m., revealed Resident #103 had a change in condition or behavior. The notes indicated onset and duration as the Resident had increased episodes of inappropriate sexual behavior. A nurse witnessed him rubbing on his roommate's arm and body. The roommate also stated that Resident #103 asked him, how big it was and can he see it. The previous night, another resident complained Resident #103 attempted to kiss him on the mouth. The notes documented the roommate was moved to another room, and Resident #103 was by himself in his room and being monitored every 30 minutes around the clock for his behaviors. The note further revealed Resident #103's level of consciousness as alert, the same as previous state and orientation to person, place, and time. Review of the facility's abuse prohibition policy, with a revision date of 9/01/16, provided by the Administrator, revealed sexual abuse includes but not limited to, sexual harassment, sexual coercion or sexual assault. The policy further revealed the definition of mental abuse is includes but not limited to humiliation, harassment, threats of punishment or deprivation. The policy indicated upon receiving information concerning a report of suspected or alleged abuse the Center Executive Director (CED) or designee would enter the allegation into the Risk Management System (RMS) and report to OHFLAC Long Term Care Department of Health and Human Resources using the Immediate Reporting Allegations form.",2020-02-01
4260,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-10-07,225,E,0,1,310011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure incidents of repeated inappropriate physical contact and language displayed by a cognitively impaired resident toward other residents were reported to the appropriate State agency. This involved discharged and current male residents and had the potential to affect all residents and staff in the facility. Resident identifiers: #103 and #146. Facility census: 69. Findings include: Review of the clinical record of Resident #103 revealed the resident was originally admitted to the facility in (MONTH) 2014 and had the following Diagnoses: [REDACTED]. During an interview, on 10/04/16 at 4:10 p.m., Nurse Aides (NA) #66 and #82 revealed they monitored Resident #103 for any inappropriate behavior. The NA's stated they were to immediately intervene if they witnessed any inappropriate behavior and report it to the charge nurse. Review of the record revealed Resident #103 had a current care plan dated 09/30/16, related to him exhibiting sexual inappropriateness. The care plan included the goal for the resident not to exhibit any acts of sexually inappropriate behavior. Care plan interventions included: --to allow the resident time to vent feelings/needs; --approach resident in a calm friendly manner; --document interventions and resident's response; --encourage family involvement; --encourage resident to attend activities of choice; --adjust time spent in activities to resident's tolerance and attention span; --identify behavior triggers and reduce exposure to triggers; --observe and document the resident's activity and whereabouts every 30 minutes; and --obtain psychological evaluation as ordered. The resident also had a current care plan initiated on 09/30/16 and revised on 10/03/16 related to exhibiting or having the potential to demonstrate verbal behaviors related to cognitive loss/dementia, poor impulse control and psychiatric disorder(s). The care plan goals stated the resident would demonstrate effective coping skills related to verbal behavior by next review; resident would not exhibit verbal outbursts direct toward others by next review and resident would verbalize understanding of triggers that result in poor impulse control and effective coping mechanisms. The care plan interventions included to: --Monitor medications, especially new/changed/discontinued, for side effects and resident's/patient's response contributing to verbal behaviors, including: antipsychotics, [MEDICATION NAME], opioids, benzodiazepines (recent discontinuation, omission or decrease in dose) drug interactions, adverse drug reactions, drug toxicity, or errors. --Evaluate the nature and circumstances (i.e., triggers) of the (resistive behavior) with resident/patient and family members/caregivers, e.g., provoked/not provoked, offensive, defensive, purposeful, during specific activities, involvement of others, patterned, easily startled, etc. --Discuss findings with resident/patient and family members/caregivers and adjust care delivery appropriately. --Evaluate need for Psych/Behavioral Health consult. --Refer resident to Psych/Behavioral Health provider to develop a Behavior Contract, if appropriate. --Provide all effective interventions (e.g., non-pharmacologic, pharmacologic) for behaviors and/or psychiatric disorder(s), (remove resident from environment) to assist resident/patient in controlling physical behaviors. --Encourage resident to seek staff support for distressed mood. --Approach the resident in a calm, unhurried manner; reassure as needed. --Remove resident from environment, if needed. --Gently guide the resident from the environment while speaking in a calm, reassuring voice. --Listen to resident and try to calm. Review of the following Minimum Data Set (MDS) assessments indicated Resident #103 was independent with transfers, and was non-ambulatory and mobile in his room and on the unit using a wheelchair: --Significant change MDS with an assessment reference date (ARD) of 09/26/16; --Quarterly MDS with an ARD of 08/11/16, 05/12/16, 08/20/15, and 05/20/15; and --Annual MDS with an ARD of 02/12/16. During interview on 10/05/16 at 9:27 a.m., the Administrator and DON revealed five (5) incidents of sexually inappropriate behavior by Resident #103 towards other residents: --On 10/29/15, Resident #103 was witnessed by staff putting his hand in the pants of a cognitively impaired resident. --On 11/12/15, Resident #103 was involved in an incident of resident to resident inappropriate physical contact with a now discharged resident. Resident #103 was reported to have rubbed the resident's leg toward the resident's groin area. --On 01/28/16, Resident #103 was involved in an incident of resident to resident physical contact with an alert and oriented resident who is now discharged . During that incident Resident #103 was noted rubbing the back of the resident's neck. --On 09/18/16, Resident #103's roommate reported the resident was playing with his toes and attempt to get into bed with him. --On 09/29/16, Resident #103 kissed the back of another resident's hand, stroked his beard and asked him to come to his room later for a kiss. The Administrator and DON verified Resident #103 had a history of [REDACTED]. The Administrator confirmed the incidents of inappropriate resident to resident physical contact were not reported to the State agency. During an interview on 10/05/16 at 11:33 a.m., Social Worker (SW) #31 stated she was working on 09/18/16 when she was informed by a Nurse Aide (NA) (she did not recall name) that Resident #103's roommate (Resident #146) reported Resident #103 had touched his toes and attempted to get in his bed. SW #31 stated she went and spoke with Resident #146 who verified the allegation. She stated Resident #146 was not upset and did not express fear of Resident #103. Resident #146 stated they had been friends for a long time and he did not feel it was a big deal. SW #31 stated she notified the Administrator immediately of the incident due to Resident #103 allegedly attempting to get into Resident #146's bed. SW #31 stated Resident #103 was moved to another room with an alert and oriented resident. Review of General Notes by Registered Nurse (RN) #40 dated 10/29/15 at 9:35 a.m., revealed after exiting Resident #103's room, RN #40 observed Resident #103 reaching in the front of another resident's pants. The notes documented RN #40 asked Resident #103 what he was doing and Resident #103 pulled his hands out of the other resident's pants, looked at RN #40 and said What? The notes documented RN #40 re-directed the resident to his room and advised him to keep his hands off of other residents. The notes documented RN #40 assisted the other resident to nursing station and advised the physician of Resident #103's behavior. Review of General Notes, dated 11/12/15 at 3:39 p.m., revealed RN #40 interviewed Resident #103's former roommate (now discharged ) as she had been advised by a staff member Resident #103 may have had inappropriate sexual contact or conversation without the former roommates consent. The notes documented Resident #103's former roommate stated about a month after he became roommates with Resident #103 he was asked by Resident #103 how big his penis was. The notes documented Resident #103 proceeded to advise his former roommate he had oral copulation with 12 to 15 men in his lifetime. The former roommate also stated that around this time he was scheduled to have a colonoscopy procedure. It was during this time, he was awakened one night by Resident #103 rubbing his bare leg and advancing toward his groin. The former roommate told Resident #103 to stop to which Resident #103 replied, But, I love you. The notes further documented the former roommate reported he told Resident #103 to stop and go away again and Resident #103 returned to his side of the room. Per the notes, the former roommate went on to report on another night around the same time he was awakened again by Resident #103 rubbing his feet. He told Resident #103 to stop and Resident #103 started kissing his former roommate's feet. The former roommate told Resident #103 to stop or he would tell the administrator and Resident #103 returned to his side of the room. The notes documented Resident #103 had not touched his former roommate since that incident. The notes further documented the former roommate stated he noticed daily when Resident #103 exited their bathroom he watched his former roommate through the cracked hinged part of the bathroom door. The former roommate stated he tried to keep his curtain pulled so that Resident #103 could not see him when he exited the bathroom. The notes documented RN #40 notified the physician, the Director of Nursing and administrator of her interview results. The notes documented Resident #103 was moved to a private room, multiple laboratory test were ordered, a geriatric psychiatry consultation and the psychologist had also been requested for consult. Review of Social Service Notes dated 11/13/15 at 12:58 p.m. revealed the Administrator, Director of Nursing (DON) and Social Worker met with Resident #103's medical power or attorney (MPOA) that same day. The notes documented the meeting was to discuss Resident #103's recent behavior which led to him being moved to a private room to protect his former roommate and also to protect Resident #103 from possible negative reactions from other resident's toward him. It was discussed the resident was scheduled to see the psychologist that weekend and he would be asked to explore with the resident the extent to which he understood why he is in a different room and make an effort to counsel the resident in regards to his behavior and to gather his recommendations for medication, ongoing counseling and possible inpatient placement. The notes documented the resident's family member advised Resident #103 now verbalized and demonstrated affection toward her (hugs, kisses, etc.) which was in stark contrast to the majority of his life. The DON advised that Resident #103 requested that morning to not have male aides work with him. Review of a Report of Consultation by the psychologist, dated 11/14/15, revealed the consult documented Resident #103 had a significant increase in sexual behaviors towards male residents. Review of a Psychiatric Consultation Log indicated an interview was conducted with Resident #103 on 11/16/15 due to the resident being referred for inappropriate behaviors of touching male residents and male staff. The Consultation findings documented Resident #103 asked if he was in trouble and if he was even capable. The findings documented Resident #103 had capacity to make medical decisions and that he denied inappropriate behaviors. The documentation revealed Resident #103 stated he is a Christian and at his church people shake hands and pat each other on the shoulder. He stated he was just joking and people took the behaviors the wrong way stating, I was just kidding them. They did not take it that way. I think that is why I am here. Review of a Report of Consultation by the psychologist, dated 11/24/15, revealed the resident was seen for a follow-up and he did not have capacity since 11/25/14. The psychologist documented he had seen the resident on several occasions and that he had a recent inappropriate sexual behavior incident that was uncharacteristic of him. The psychologist documented Resident #103 did not appear to recall his behavior and that his [MEDICATION NAME] was increased on 11/12/15 with appears to have had positive results. Review of General Notes, dated 01/14/16 at 9:45 p.m., found at approximately 7:15 p.m. Resident #103 was propelling in his wheelchair down the 200 hallway towards another resident's room (resident now discharged ) when he attempted to open the other resident's door. The notes documented the nurse interfered and informed Resident #103 he could not go into that room, that if the other resident wanted a visitor then he would seek him out. The notes documented Resident #103 got angry and stated the other resident had invited him to his room at dinner time. The nurse again stated to Resident #103 if the other resident wanted a visitor he would come seek him. Resident #103 appeared very agitated and yelled, Who are you?! and, Are you the boss?! The notes documented the nurse re-educated Resident #103 again that he was not allowed in the room and he finally went back to his own room. General Notes, dated 01/15/16 at 2:56 p.m., documented Resident #103 again attempted twice to go in the other resident's room (same now discharged resident) by attempting to open the door to room. The notes documented Resident #103 was instructed to please go to his room or another area of the facility. The notes documented Resident #103 stated he was invited to the other resident's room. The notes document the other resident was interviewed and stated no invitation was made. The notes documented Resident #103 stated he was tired of you people treating me like dirt, but he complied and went back to his room. General notes indicated staff were to continue to monitor and re-educate the resident as necessary. General Notes, dated 01/15/16 at 5:15 p.m., documented Resident #103 was found in the other resident's room (same now discharged resident) by a N[NAME] The notes documented Resident #103 was asking the other resident for his address. The NA then asked the other resident if he wanted Resident #103 to have his address to which the other resident stated no. The notes documented the NA then tried to redirect Resident #103 out of the resident's room and Resident #103 told the NA, Leave me alone you [***] ! and as the NA was escorting Resident #103 out of the room he swung and tried to hit her. The notes documented the nurse and nursing supervisor tried to talk to Resident #103 and redirect and Resident #103 stated, You are a[***]y supervisor! The notes documented Resident #103 was redirected to his room shouting, I will have your jobs! The physician was notified and ordered an antipsychotic medication ([MEDICATION NAME] 5 mg) intramuscularly once at that time for combative behavior and agitation. Review on 10/05/16 revealed a General Late Entry Notes, dated 01/28/16 at 3:40 p.m., documented Resident #103 was following another male resident to his room and was asked and re-directed to his room on another hall. The note documented, less than 5 minutes later, Resident #103 went into another resident's room in his wheelchair and the nurse was observing. The notes documented Resident #103 was gently rubbing the back and neck of the resident in the room and the resident stated. No, no, no, and was trying to get away from Resident #103. The nurse then removed Resident #103 from that room and hall, and re-directed him to the hall he resided on. The notes documented Resident #103 raised his voice yelling, Don ' t tell me what I can and don ' t tell me what I can and can ' t do! The incident was reported to the DON. Review of General Notes, dated 01/29/16 at 2:26 p.m., revealed Resident #103 followed another male resident around the facility and wanted to know if he could be roommates with that resident. The notes stated Resident #103 wanted to know if he could go to his room with him. The notes stated Resident #103 was re-directed four times that shift. Review of General Notes, dated 01/29/16 at 2:52 p.m., revealed Resident #103 was sticking his finger down his throat and gagging in hallway and when asked if he was okay, Resident #103 stated, Yeah can I go to his room now? The notes stated Resident #103 was referring to another male resident (noted in the General Notes on 01/29/16 at 2:26 p.m.) and Resident #103 was redirected. Review of the Physician Determination of Capacity, dated 05/10/16, revealed Resident #103 was assessed to lack sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. The document indicated the [DIAGNOSES REDACTED]. The nature of the incapacitation was indicated as evidenced by cognitive loss, inappropriate answers to questions and inability to understand or make medical decisions. The expected duration of the resident's incapacity was indicated as long term. Review of General Notes, dated 06/01/16 at 2:54 p.m., revealed orders were written for Resident #103 to have a consultation with the psychiatrist due to predatory behavior. A Report of Consultation, dated 06/3/16, documented the psychologist saw Resident #103 on several occasions due to similar concerns, most recent 12/22/15. The psychologist documented inappropriate sexual behavior (ISB) is not uncommon with dementia. Resident made inappropriate comments to residents. Review of General Notes by Social Worker #31, dated 09/18/16 at 3:08 p.m., revealed she was approached by a NA who stated Resident #103's roommate alleged Resident #103 was inappropriate with him. SW #31 documented she interviewed Resident #103's roommate who stated Resident #103 played with his toes and attempted to get in bed with him. The roommate indicated Resident #103 had displayed inappropriate behaviors. Review of the licensed social worker's psychiatric consultation log revealed Resident #103 was referred due to sexually inappropriate behaviors and was interviewed on 09/20/16. The consultation findings revealed Resident #103 was having sexually inappropriate behaviors and was moved to another room. The documentation stated Resident #103's new roommate was oriented and Resident #103 sleeps most of the day and is then up and out at night. He was reported by a peer that he touched him. Per staff report Resident #103 stated this did occur. Review of another psychiatric consultation log by the licensed social worker (LSW) from the local hospital behavioral department also with an interview date of 09/20/16, revealed the findings of the interview documented Resident #103 stated he was sorry. He stated it would not happen again. He stated it is, over with and that his roommate is not his type. He stated that it had not happened before. LSW documented it was charted he had past events. The LSW documented in the findings Resident #103 stated he could control his feelings. Review of a Physician Determination of Capacity form, dated 09/27/16, revealed the psychologist certified the Resident #103 lacked sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. The documentation indicated the nature of the incapacity was evidenced by cognitive loss, inappropriate answers to questions and inability to understand or make medical decisions. The expected duration of the incapacity was indicated as long term. Review of Care Plan Evaluation Notes, dated 09/28/16 at 9:06 a.m., revealed a significant change assessment was completed for Resident #103 for behaviors of sexual inappropriateness with previous roommate and nursing staff since last review on 08/11/16. Review of Social Service Late Entry Notes, dated 09/29/16 at 2:26 p.m., revealed SW #31 was told Resident #103 had made inappropriate advances to another resident. SW #31 interviewed the other resident who stated Resident #103 kissed the back of his hand, stroked his beard and asked him to come to his room later for a kiss. The other resident stated he didn't feel violated. SW #31 documented she brought Resident #112 to her office to discuss this allegation and while pushing the resident's wheelchair to the front of the facility Resident #103 asked this same male resident to come see him in his room. Resident #103 told the other male resident he had the room to himself and was lonely. The other resident told him he wasn't interested. SW #31 documented that within minutes Resident #103 asked the same resident again to come see him in his room. SW #31 and the DON spoke with Resident #103 regarding these allegations. SW #31 documented Resident #103 did not deny or admit to the allegations. SW #31 documented they explained to Resident #103 his behavior wasn't appropriate and advised him to refrain from touching and propositioning other residents. Review of General Notes, dated 09/29/16 at 6:30 p.m., revealed Resident #103 was noted to be alone in his room with his roommate while his daughters were present in facility but visiting another resident in their room at that time. The notes documented Resident #103 was noted to be holding/patting his roommate's left hand and his roommate told him to, go visit with your daughters and repeatedly told Resident #103, thank you, ok, goodbye. The notes documented Resident #103's due to a medical condition the roommate was unable to remove his left hand from Resident #103's reach. The notes documented Resident #103 was redirected to the restorative dining room with both his daughters. The DON and administrator notified at that time with recommendations to move Resident #103 to another room. According to facility documentation of Resident #103's activity and whereabouts on 09/29/16, Resident #103 was in the dining room with family at 6:00 p.m., in his room alone holding his roommate's hand at 6:15 p.m. and in the restorative dining room with family at 6:30 p.m. There was no evidence the resident's level of supervision was increased beyond the every 30 minute checks after he was again noted displaying unwanted resident to resident physical contact. Review of General Notes, dated 09/29/16 at 6:45 p.m., revealed RN #40 spoke with Resident #103's family inquiring if they were aware of Resident #103's behavior that day related to him being inappropriate with two alert and oriented residents. The notes stated that during this meeting a nurse came to staff and the family that Resident #103 was asking his roommate at that very moment about the size of his penis. Review of General Notes, dated 09/29/16 at 7:20 p.m., revealed Resident #103's roommate reported to a NA that Resident #103 asked him, how big is his penis and if, he could see it. The note revealed the roommate was interviewed at that time and he reported, (Resident #103's name) always asks me how big ' it ' is and if he can see it. Review of the Change in Condition Notes, dated 09/29/16 at 11:04 p.m., revealed Resident #103 had a change in condition or behavior. The notes indicated onset and duration as the Resident had increased episodes of inappropriate sexual behavior. A nurse witnessed him rubbing on his roommate's arm and body. The roommate also stated that Resident #103 asked him, how big it was and can he see it. The previous night, another resident complained Resident #103 attempted to kiss him on the mouth. The notes documented the roommate was moved to another room, and Resident #103 was by himself in his room and being monitored every 30 minutes around the clock for his behaviors. The note further revealed Resident #103's level of consciousness as alert, the same as previous state and orientation to person, place, and time. Review of the facility's abuse prohibition policy, with a revision date of 9/01/16, provided by the Administrator, revealed sexual abuse includes but not limited to, sexual harassment, sexual coercion or sexual assault. The policy further revealed the definition of mental abuse is includes but not limited to humiliation, harassment, threats of punishment or deprivation. The policy indicated upon receiving information concerning a report of suspected or alleged abuse the Center Executive Director (CED) or designee would enter the allegation into the Risk Management System (RMS) and report to OHFLAC Long Term Care Department of Health and Human Resources using the Immediate Reporting Allegations form.",2020-02-01
4261,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-10-07,226,E,0,1,310011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to operationalize the facility ' s abuse prohibition policy to prevent incidents of repeated inappropriate physical contact and language displayed by a cognitively impaired resident toward other residents. In addition, these incidents were not reported to the appropriate State agency in accordance with facility policy. This involved discharged and current male residents and had the potential to affect all residents and staff in the facility. Resident identifiers: #103 and #146. Facility census: 69. Findings include: Review of the clinical record of Resident #103 revealed the resident was originally admitted to the facility in (MONTH) 2014 and had the following Diagnoses: [REDACTED]. During an interview, on 10/04/16 at 4:10 p.m., Nurse Aides (NA) #66 and #82 revealed they monitored Resident #103 for any inappropriate behavior. The NA's stated they were to immediately intervene if they witnessed any inappropriate behavior and report it to the charge nurse. Review of the record revealed Resident #103's had a current care plan, dated 09/30/16, related to him exhibiting sexual inappropriateness. The care plan included the goal for the resident not to exhibit any acts of sexually inappropriate behavior. Care plan interventions included: --to allow the resident time to vent feelings/needs; --approach resident in a calm friendly manner; --document interventions and resident's response; --encourage family involvement; --encourage resident to attend activities of choice; --adjust time spent in activities to resident's tolerance and attention span; --identify behavior triggers and reduce exposure to triggers; --observe and document the resident's activity and whereabouts every 30 minutes; and --obtain psychological evaluation as ordered. The resident also had a current care plan initiated on 09/30/16 and revised on 10/03/16 related to exhibiting or having the potential to demonstrate verbal behaviors related to: cognitive loss/dementia, poor impulse control and psychiatric disorder(s). The care plan goals stated the resident would demonstrate effective coping skills related to verbal behavior by next review; resident would not exhibit verbal outbursts direct toward others by next review and resident would verbalize understanding of triggers that result in poor impulse control and effective coping mechanisms. The care plan interventions included to: --Monitor medications, especially new/changed/discontinued, for side effects and resident's/patient's response contributing to verbal behaviors, including: antipsychotics, [MEDICATION NAME], opioids, benzodiazepines (recent discontinuation, omission or decrease in dose) drug interactions, adverse drug reactions, drug toxicity, or errors. --Evaluate the nature and circumstances (i.e., triggers) of the (resistive behavior) with resident/patient and family members/caregivers, e.g., provoked/not provoked, offensive, defensive, purposeful, during specific activities, involvement of others, patterned, easily startled, etc. --Discuss findings with resident/patient and family members/caregivers and adjust care delivery appropriately. --Evaluate need for Psych/Behavioral Health consult. --Refer resident to Psych/Behavioral Health provider to develop a Behavior Contract, if appropriate. --Provide all effective interventions (e.g., non-pharmacologic, pharmacologic) for behaviors and/or psychiatric disorder(s), (remove resident from environment) to assist resident/patient in controlling physical behaviors. --Encourage resident to seek staff support for distressed mood. --Approach the resident in a calm, unhurried manner; reassure as needed. --Remove resident from environment, if needed. --Gently guide the resident from the environment while speaking in a calm, reassuring voice. --Listen to resident and try to calm. Review of the following Minimum Data Set (MDS) assessments indicated Resident #103 was independent with transfers, and was non-ambulatory and mobile in his room and on the unit using a wheelchair: --Significant change MDS with an assessment reference date (ARD) of 09/26/16; --Quarterly MDS with an ARD of 08/11/16, 05/12/16, 08/20/15, and 05/20/15; and --Annual MDS with an ARD of 02/12/16. During interview on 10/05/16 at 9:27 a.m., the Administrator and DON revealed five (5) incidents of sexually inappropriate behavior by Resident #103 towards other residents: --On 10/29/15, Resident #103 was witnessed by staff putting his hand in the pants of a cognitively impaired resident. --On 11/12/15, Resident #103 was involved in an incident of resident to resident inappropriate physical contact with a now discharged resident. Resident #103 was reported to have rubbed the resident's leg toward the resident's groin area. --On 01/28/16, Resident #103 was involved in an incident of resident to resident physical contact with an alert and oriented resident who is now discharged . During that incident Resident #103 was noted rubbing the back of the resident's neck. --On 09/18/16, Resident #103's roommate reported the resident was playing with his toes and attempt to get into bed with him. --On 09/29/16, Resident #103 kissed the back of another resident's hand, stroked his beard and asked him to come to his room later for a kiss. The Administrator and DON verified Resident #103 had a history of [REDACTED]. The Administrator confirmed the incidents of inappropriate resident to resident physical contact were not reported to the State agency. During an interview on 10/05/16 at 11:33 a.m., Social Worker (SW) #31 stated she was working on 09/18/16 when she was informed by a Nurse Aide (NA) (she did not recall name) that Resident #103's roommate (Resident #146) reported Resident #103 had touched his toes and attempted to get in his bed. SW #31 stated she went and spoke with Resident #146 who verified the allegation. She stated Resident #146 was not upset and did not express fear of Resident #103. Resident #146 stated they had been friends for a long time and he did not feel it was a big deal. SW #31 stated she notified the Administrator immediately of the incident due to Resident #103 allegedly attempting to get into Resident #146's bed. SW #31 stated Resident #103 was moved to another room with an alert and oriented resident. Review of General Notes by Registered Nurse (RN) #40 dated 10/29/15 at 9:35 a.m., revealed after exiting Resident #103's room, RN #40 observed Resident #103 reaching in the front of another resident's pants. The notes documented RN #40 asked Resident #103 what he was doing and Resident #103 pulled his hands out of the other resident's pants, looked at RN #40 and said What? The notes documented RN #40 re-directed the resident to his room and advised him to keep his hands off of other residents. The notes documented RN #40 assisted the other resident to nursing station and advised the physician of Resident #103's behavior. Review of General Notes, dated 11/12/15 at 3:39 p.m., revealed RN #40 interviewed Resident #103's former roommate (now discharged ) as she had been advised by a staff member Resident #103 may have had inappropriate sexual contact or conversation without the former roommates consent. The notes documented Resident #103's former roommate stated about a month after he became roommates with Resident #103 he was asked by Resident #103 how big his penis was. The notes documented Resident #103 proceeded to advise his former roommate he had oral copulation with 12 to 15 men in his lifetime. The former roommate also stated that around this time he was scheduled to have a colonoscopy procedure. It was during this time, he was awakened one night by Resident #103 rubbing his bare leg and advancing toward his groin. The former roommate told Resident #103 to stop to which Resident #103 replied, But, I love you. The notes further documented the former roommate reported he told Resident #103 to stop and go away again and Resident #103 returned to his side of the room. Per the notes, the former roommate went on to report on another night around the same time he was awakened again by Resident #103 rubbing his feet. He told Resident #103 to stop and Resident #103 started kissing his former roommate's feet. The former roommate told Resident #103 to stop or he would tell the administrator and Resident #103 returned to his side of the room. The notes documented Resident #103 had not touched his former roommate since that incident. The notes further documented the former roommate stated he noticed daily when Resident #103 exited their bathroom he watched his former roommate through the cracked hinged part of the bathroom door. The former roommate stated he tried to keep his curtain pulled so that Resident #103 could not see him when he exited the bathroom. The notes documented RN #40 notified the physician, the Director of Nursing and administrator of her interview results. The notes documented Resident #103 was moved to a private room, multiple laboratory test were ordered, a geriatric psychiatry consultation and the psychologist had also been requested for consult. Review of Social Service Notes dated 11/13/15 at 12:58 p.m. revealed the Administrator, Director of Nursing (DON) and Social Worker met with Resident #103's medical power or attorney (MPOA) that same day. The notes documented the meeting was to discuss Resident #103's recent behavior which led to him being moved to a private room to protect his former roommate and also to protect Resident #103 from possible negative reactions from other resident's toward him. It was discussed the resident was scheduled to see the psychologist that weekend and he would be asked to explore with the resident the extent to which he understood why he is in a different room and make an effort to counsel the resident in regards to his behavior and to gather his recommendations for medication, ongoing counseling and possible inpatient placement. The notes documented the resident's family member advised Resident #103 now verbalized and demonstrated affection toward her (hugs, kisses, etc.) which was in stark contrast to the majority of his life. The DON advised that Resident #103 requested that morning to not have male aides work with him. Review of a Report of Consultation by the psychologist, dated 11/14/15, revealed the consult documented Resident #103 had a significant increase in sexual behaviors towards male residents. Review of a Psychiatric Consultation Log indicated an interview was conducted with Resident #103 on 11/16/15 due to the resident being referred for inappropriate behaviors of touching male residents and male staff. The Consultation findings documented Resident #103 asked if he was in trouble and if he was even capable. The findings documented Resident #103 had capacity to make medical decisions and that he denied inappropriate behaviors. The documentation revealed Resident #103 stated he is a Christian and at his church people shake hands and pat each other on the shoulder. He stated he was just joking and people took the behaviors the wrong way stating, I was just kidding them. They did not take it that way. I think that is why I am here. Review of a Report of Consultation by the psychologist, dated 11/24/15, revealed the resident was seen for a follow-up and he did not have capacity since 11/25/14. The psychologist documented he had seen the resident on several occasions and that he had a recent inappropriate sexual behavior incident that was uncharacteristic of him. The psychologist documented Resident #103 did not appear to recall his behavior and that his [MEDICATION NAME] was increased on 11/12/15 with appears to have had positive results. Review of General Notes, dated 01/14/16 at 9:45 p.m., found at approximately 7:15 p.m. Resident #103 was propelling in his wheelchair down the 200 hallway towards another resident's room (resident now discharged ) when he attempted to open the other resident's door. The notes documented the nurse interfered and informed Resident #103 he could not go into that room, that if the other resident wanted a visitor then he would seek him out. The notes documented Resident #103 got angry and stated the other resident had invited him to his room at dinner time. The nurse again stated to Resident #103 if the other resident wanted a visitor he would come seek him. Resident #103 appeared very agitated and yelled, Who are you?! and, Are you the boss?! The notes documented the nurse re-educated Resident #103 again that he was not allowed in the room and he finally went back to his own room. General Notes, dated 01/15/16 at 2:56 p.m., documented Resident #103 again attempted twice to go in the other resident's room (same now discharged resident) by attempting to open the door to room. The notes documented Resident #103 was instructed to please go to his room or another area of the facility. The notes documented Resident #103 stated he was invited to the other resident's room. The notes document the other resident was interviewed and stated no invitation was made. The notes documented Resident #103 stated he was tired of you people treating me like dirt, but he complied and went back to his room. General notes indicated staff were to continue to monitor and re-educate the resident as necessary. General Notes, dated 01/15/16 at 5:15 p.m., documented Resident #103 was found in the other resident's room (same now discharged resident) by a N[NAME] The notes documented Resident #103 was asking the other resident for his address. The NA then asked the other resident if he wanted Resident #103 to have his address to which the other resident stated no. The notes documented the NA then tried to redirect Resident #103 out of the resident's room and Resident #103 told the NA, Leave me alone you [***] ! and as the NA was escorting Resident #103 out of the room he swung and tried to hit her. The notes documented the nurse and nursing supervisor tried to talk to Resident #103 and redirect and Resident #103 stated, You are a[***]y supervisor! The notes documented Resident #103 was redirected to his room shouting, I will have your jobs! The physician was notified and ordered an antipsychotic medication ([MEDICATION NAME] 5 mg) intramuscularly once at that time for combative behavior and agitation. Review on 10/05/16 revealed a General Late Entry Notes, dated 01/28/16 at 3:40 p.m., documented Resident #103 was following another male resident to his room and was asked and re-directed to his room on another hall. The note documented, less than 5 minutes later, Resident #103 went into another resident's room in his wheelchair and the nurse was observing. The notes documented Resident #103 was gently rubbing the back and neck of the resident in the room and the resident stated. No, no, no, and was trying to get away from Resident #103. The nurse then removed Resident #103 from that room and hall, and re-directed him to the hall he resided on. The notes documented Resident #103 raised his voice yelling, Don ' t tell me what I can and don ' t tell me what I can and can ' t do! The incident was reported to the DON. Review of General Notes, dated 01/29/16 at 2:26 p.m., revealed Resident #103 followed another male resident around the facility and wanted to know if he could be roommates with that resident. The notes stated Resident #103 wanted to know if he could go to his room with him. The notes stated Resident #103 was re-directed four times that shift. Review of General Notes, dated 01/29/16 at 2:52 p.m., revealed Resident #103 was sticking his finger down his throat and gagging in hallway and when asked if he was okay, Resident #103 stated, Yeah can I go to his room now? The notes stated Resident #103 was referring to another male resident (noted in the General Notes on 01/29/16 at 2:26 p.m.) and Resident #103 was redirected. Review of the Physician Determination of Capacity, dated 05/10/16, revealed Resident #103 was assessed to lack sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. The document indicated the [DIAGNOSES REDACTED]. The nature of the incapacitation was indicated as evidenced by cognitive loss, inappropriate answers to questions and inability to understand or make medical decisions. The expected duration of the resident's incapacity was indicated as long term. Review of General Notes, dated 06/01/16 at 2:54 p.m., revealed orders were written for Resident #103 to have a consultation with the psychiatrist due to predatory behavior. A Report of Consultation, dated 06/3/16, documented the psychologist saw Resident #103 on several occasions due to similar concerns, most recent 12/22/15. The psychologist documented inappropriate sexual behavior (ISB) is not uncommon with dementia. Resident made inappropriate comments to residents. Review of General Notes by Social Worker #31, dated 09/18/16 at 3:08 p.m., revealed she was approached by a NA who stated Resident #103's roommate alleged Resident #103 was inappropriate with him. SW #31 documented she interviewed Resident #103's roommate who stated Resident #103 played with his toes and attempted to get in bed with him. The roommate indicated Resident #103 had displayed inappropriate behaviors. Review of the licensed social worker's psychiatric consultation log revealed Resident #103 was referred due to sexually inappropriate behaviors and was interviewed on 09/20/16. The consultation findings revealed Resident #103 was having sexually inappropriate behaviors and was moved to another room. The documentation stated Resident #103's new roommate was oriented and Resident #103 sleeps most of the day and is then up and out at night. He was reported by a peer that he touched him. Per staff report Resident #103 stated this did occur. Review of another psychiatric consultation log by the licensed social worker (LSW) from the local hospital behavioral department also with an interview date of 09/20/16, revealed the findings of the interview documented Resident #103 stated he was sorry. He stated it would not happen again. He stated it is, over with and that his roommate is not his type. He stated that it had not happened before. LSW documented it was charted he had past events. The LSW documented in the findings Resident #103 stated he could control his feelings. Review of a Physician Determination of Capacity form, dated 09/27/16, revealed the psychologist certified the Resident #103 lacked sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. The documentation indicated the nature of the incapacity was evidenced by cognitive loss, inappropriate answers to questions and inability to understand or make medical decisions. The expected duration of the incapacity was indicated as long term. Review of Care Plan Evaluation Notes, dated 09/28/16 at 9:06 a.m., revealed a significant change assessment was completed for Resident #103 for behaviors of sexual inappropriateness with previous roommate and nursing staff since last review on 08/11/16. Review of Social Service Late Entry Notes, dated 09/29/16 at 2:26 p.m., revealed SW #31 was told Resident #103 had made inappropriate advances to another resident. SW #31 interviewed the other resident who stated Resident #103 kissed the back of his hand, stroked his beard and asked him to come to his room later for a kiss. The other resident stated he didn't feel violated. SW #31 documented she brought Resident #112 to her office to discuss this allegation and while pushing the resident's wheelchair to the front of the facility Resident #103 asked this same male resident to come see him in his room. Resident #103 told the other male resident he had the room to himself and was lonely. The other resident told him he wasn't interested. SW #31 documented that within minutes Resident #103 asked the same resident again to come see him in his room. SW #31 and the DON spoke with Resident #103 regarding these allegations. SW #31 documented Resident #103 did not deny or admit to the allegations. SW #31 documented they explained to Resident #103 his behavior wasn't appropriate and advised him to refrain from touching and propositioning other residents. Review of General Notes, dated 09/29/16 at 6:30 p.m., revealed Resident #103 was noted to be alone in his room with his roommate while his daughters were present in facility but visiting another resident in their room at that time. The notes documented Resident #103 was noted to be holding/patting his roommate's left hand and his roommate told him to, go visit with your daughters and repeatedly told Resident #103, thank you, ok, goodbye. The notes documented Resident #103's due to a medical condition the roommate was unable to remove his left hand from Resident #103's reach. The notes documented Resident #103 was redirected to the restorative dining room with both his daughters. The DON and administrator notified at that time with recommendations to move Resident #103 to another room. According to facility documentation of Resident #103's activity and whereabouts on 09/29/16, Resident #103 was in the dining room with family at 6:00 p.m., in his room alone holding his roommate's hand at 6:15 p.m. and in the restorative dining room with family at 6:30 p.m. There was no evidence the resident's level of supervision was increased beyond the every 30 minute checks after he was again noted displaying unwanted resident to resident physical contact. Review of General Notes, dated 09/29/16 at 6:45 p.m., revealed RN #40 spoke with Resident #103's family inquiring if they were aware of Resident #103's behavior that day related to him being inappropriate with two alert and oriented residents. The notes stated that during this meeting a nurse came to staff and the family that Resident #103 was asking his roommate at that very moment about the size of his penis. Review of General Notes, dated 09/29/16 at 7:20 p.m., revealed Resident #103's roommate reported to a NA that Resident #103 asked him, how big is his penis and if, he could see it. The note revealed the roommate was interviewed at that time and he reported, (Resident #103's name) always asks me how big ' it ' is and if he can see it. Review of the Change in Condition Notes, dated 09/29/16 at 11:04 p.m., revealed Resident #103 had a change in condition or behavior. The notes indicated onset and duration as the Resident had increased episodes of inappropriate sexual behavior. A nurse witnessed him rubbing on his roommate's arm and body. The roommate also stated that Resident #103 asked him, how big it was and can he see it. The previous night, another resident complained Resident #103 attempted to kiss him on the mouth. The notes documented the roommate was moved to another room, and Resident #103 was by himself in his room and being monitored every 30 minutes around the clock for his behaviors. The note further revealed Resident #103's level of consciousness as alert, the same as previous state and orientation to person, place, and time. Review of the facility's abuse prohibition policy, with a revision date of 9/01/16, provided by the Administrator, revealed sexual abuse includes but not limited to, sexual harassment, sexual coercion or sexual assault. The policy further revealed the definition of mental abuse is includes but not limited to humiliation, harassment, threats of punishment or deprivation. The policy indicated upon receiving information concerning a report of suspected or alleged abuse the Center Executive Director (CED) or designee would enter the allegation into the Risk Management System (RMS) and report to OHFLAC Long Term Care Department of Health and Human Resources using the Immediate Reporting Allegations form",2020-02-01
4262,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-10-07,242,E,0,1,310011,"Based on family interview, resident interview, staff interview, observation and record review, the facility failed to proactively offer residents personal choices regarding their bed time and wake up time and/or their shower day and time for three (3) of three (3) resident reviewed for choices. This failed practice had the potential to affect more than a limited number of people. Resident identifiers: #5, #127, and #31. Facility census: 69. Findings include: a) Resident #6 Resident #6, who is cognitively impaired, was admitted to the facility in 2008. During an interview with a family member of Resident #6 on 10/04/16 at 11:15 a.m., a preference was voiced for the resident's wake-up and bed times. The family's preference was for the resident to be in bed by 8:00 p.m., and awakened and dressed as close to breakfast service at 8:30 a.m. as possible. A review of the resident's care plan revealed the plan was specific regarding bed time but not the resident's morning wake-up time. Interview with facility Activity Director #4, on 10/05/16 at 11:00 a.m., revealed that activity staff routinely ask initial assessment questions regarding whether residents have a preference for bed time and wake-up time. That information is conveyed to nursing staff as plans of care are developed. Activity Director #4 further stated she had developed the assessment form since Resident #6's initial admission to the facility; therefore, she did not have responses on file for the resident. Interview with nurse aide (NA) #63 on 10/05/16 at 7:10 a.m. revealed she was responsible for ensuring residents were up and dressed for breakfast and/or therapy. She explained the schedule for getting residents up was based on their therapy schedule. She stated each day therapy staff develops a list of residents for scheduled therapy and it is posted on the inside of the charting room door. Staff then look to that list for the priority regarding what time to get residents up. Any resident who is not scheduled for therapy is fit into the schedule when the therapy residents have been accommodated. The schedule is not based on personal resident preferences; rather, it is based on the therapy schedule. On 10/05/16, Resident #6 was observed out of bed and dressed at 6:15 a.m. Breakfast was served and assistance offered to Resident #6 at 8:30 a.m. b) Resident #127 During interview on 10/03/16 at 10:16 a.m., Resident #127 stated he did not have a choice regarding when he received a shower. He stated he received two showers per week however, he did not have a choice regarding which days or time of day that he is showered. Per the facility schedule Resident #127's two showers per week were scheduled for Wednesdays and Sundays on the evening shift. Review of the 08/29/16 Resident Council Minutes on 10/04/16 at 2:00 p.m. revealed a concern had been raised by the residents regarding shower times. The minutes stated the residents would like to know the approximate time of scheduled showers on shower days. The Department Response form addressing the raised concern showed that nursing had responded to the concern with: We will, with the assistance of guest services, interview all residents. We will try to give the residents preference of shower time consideration and adjust as possible. During interview on 10/04/16 at 3:08 p.m. with shower aide/nurse aide (NA) #74, she identified the shower schedule documentation that she followed. The form outlined by day and shift which resident room numbers are showered on which days and shifts. There were two handwritten notes entered into the grid identifying a resident who wanted a shower before lunch time and another who wanted her shower before a regularly scheduled hair appointment. During interview on 10/04/16 at 3:15 p.m., the Director of Nursing (DON) was asked about his response to the issue raised during the 08/29/16 resident council meeting. The DON responded he had delegated the interviews to the facility Guest Services Director (GSD) #1. Interview on 10/04/16 at 3:20 p.m. with Guest Services Director #1 regarding the resident council response to interviewing all residents regarding their shower preferences, revealed GSD#1 stated she had completed the interviews requested by the DON in (MONTH) on a form provided by the DON and had returned the form to the DON. Further interview with the DON on 10/04/16 at 3:25 p.m. regarding the results of the resident interviews, revealed he provided a form entitled, Residents with Shower Preferences. Six residents were included on the form. The facility census was 69. This form was located in the facility shower book. Shower aide/NA #74, acknowledged familiarity with the form on 10/04/16. c) Resident #31 Resident #31 was admitted to the facility during (MONTH) (YEAR). During interview on 10/03/16 at 1:50 p.m., Resident #31 stated she was assigned Wednesdays and Saturdays as her shower days and that she was not given a choice. On 10/05/16 at 1:02 p.m., a list of resident room numbers and days of the week was reviewed after being provided by nurse aide (NA) #77. NA #77 noted that residents were assigned showers based on the room they resided in. On 10/05/16 at 12:35 p.m., an interview was completed with Registered Nurse (RN) #40 who stated she was a supervisor and worked with many residents to complete admission assessments. RN #40 stated the resident shower schedule had been in place since before she was employed at the facility and that it was set up by bed. She stated whoever was in the particular bed, received showers on a certain two days. RN #40 stated she tells residents upon their admission to the facility that they will get showers a couple days a week. She said the aide that gives showers tells the residents what days they will get their showers. RN #40 stated she had never heard anyone ask if they wanted to change their shower but some residents ask to change and they try to accommodate them. During interview on 10/05/16 at 1:25 p.m., NA #77 stated she was the shower aide for the day. NA #77 stated, We have a list of what showers to do each day. Residents are assigned shower days based on the room they are admitted to. Review of Resident Council Meeting minutes for (MONTH) 29, (YEAR) noted residents requested to know the time of scheduled showers on their shower days. The undated and unsigned Department Response Form noted, We will, with the assistance of guest services, interview all residents, (sic) we will try to give the resident's preferences of shower time consideration and adjust as possible. During interview on 10/06/16 at 8:55 a.m., Guest Services Director (GSD) #1 stated, I have an interview process for new admissions. We see how the transition was, let them know about activities and meals. It's really an orientation. Yesterday (10/05/16) we added a question asking if shower times were acceptable. Before I asked how things were going with showers, but it wasn't on the form. A form identified by GSD #1 as the questionnaire that she uses was reviewed. She noted that she added the question, Is your current shower time acceptable on 10/05/16. There were no questions on the form related to the days of showers or the type of bathing.",2020-02-01
4263,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-10-07,368,C,0,1,310011,"Based on observation, staff interview and review of the facility posted meal service time, the facility had routinely scheduled the evening meal and the next breakfast meal 14.5 hours apart. This had the potential to affect all residents served meals in the facility. Facility census: 69. Findings include: Observation on 10/03/16 revealed the meal times posted in the facility were: Breakfast --Hall #100 at 7:30 a.m. --Hall #200 / Private Dining Room at 7:40 a.m. --Main Dining Room at 7:45 a.m. --Hall #300 at 7:50 a.m. --Hall #400 at 8:00 a.m. Lunch Service --Hall #100 at noon --Hall #200 / Private Dining Room at 12:10 p.m. --Hall #300 at 12:15 p.m. --Hall #400 at 12:20 p.m. --Main Dining Room at 12:30 p.m. Dinner Service --Hall #100 at 5:00 p.m. --Hall #200 / Private Dining at 5:10 p.m. --Hall #300 at 5:15 p.m. --Hall #400 at 5:20 p.m. --Main Dining Room at 5:30 p.m. The posted meal schedule exceeds the 14 hour limit between the evening dinner meal and breakfast the following morning. During interview on 10/05/16 at 10 a.m., Food Service Manager #10 stated he had become the department manager in (MONTH) (YEAR) and that the current meal times were established before his arrival and had not been adjusted since his arrival. Food Service Manager #10 confirmed during the interview that the dietary department stocked nourishments to a room located near the nursing station. However, there was no plan to approach each resident and offer a nourishing snack each evening. The available floor stock nourishments were only available upon resident request.",2020-02-01
4264,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-10-07,431,E,0,1,310011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to properly label opened multi-use vials of Purified Protein Derivative. This had the potential to affect all newly admitted residents and current residents requiring updated [DIAGNOSES REDACTED] monitoring. Facility census: 69. Findings include: Observation on 10/03/16 at 9:09 a.m. of the facility medication storage area revealed there was 4 vials of opened Purified Protein Derivative (PPD). Two of the vials were not labeled with the date they had been opened, one vial had a date that was not legible (the date was either 7/26 or 9/26.) Interview with Licensed Practical Nurse (LPN) #48 verified the findings. LPN #48 stated, Vials opened are good for 30 days. I think that night shift checks the temperatures. I'm not sure if it is their job to check dates. I will find out. On 10/03/16 at 9:15 a.m., LPN #53 stated, I verified with our nurse educator. She says that whoever opens the vial should date it. It is everyone's responsibility to look at expiration dates. It isn't assigned to anyone. I am going to throw all of those away.",2020-02-01
4265,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-10-07,467,B,0,1,310011,"Based on observation and staff interview, the ventilation system for the facility's one common shower room, used by all facility residents, was not operational. This had the potential to affect all residents provided bathing care in the common shower area. Facility census 69. Findings include: During an observation of the shower area on 10/04/16 at 4:00 p.m. with the shower aide/nurse aide (NA) #74, the room was noted very humid and air movement could not be detected. A follow-up observation was conducted with the Maintenance Director #19 on 10/04/16 at 4:30 p.m. Maintenance Director #19 then went to the building roof to check on the status of the system and reported back that the air exchange system in the shower room was not working. He stated that during his inspection last month it had been working correctly and he had been unaware that the ventilation was not currently working. He explained that he would order a replacement motor later in the day on 10/04/16 with the expectation that it would be delivered on 10/06/16 and would be installed on 10/06/16. There was a window observed in the shower room that could be opened for ventilation; however, it was not observed open on 10/04/16 or 10/05/16.",2020-02-01
4266,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-10-07,520,E,0,1,310011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to address, through the quality assessment and assurance committee, incidents of inappropriate sexual behavior by a cognitively impaired resident. This included the prevention of repeated inappropriate physical and sexual contact and language with other current and discharged residents and staff. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #103 and #146. Facility census: 69. Findings include: Review of the clinical record of Resident #103 revealed the resident was originally admitted to the facility in (MONTH) 2014 and had the following Diagnoses: [REDACTED]. During an interview, on 10/04/16 at 4:10 p.m., Nurse Aides (NA) #66 and #82 revealed they monitored Resident #103 for any inappropriate behavior. The NA's stated they were to immediately intervene if they witnessed any inappropriate behavior and report it to the charge nurse. Review of the record revealed Resident #103's had a current care plan, dated 09/30/16, related to him exhibiting sexual inappropriateness. The care plan included the goal for the resident not to exhibit any acts of sexually inappropriate behavior. Care plan interventions included: --to allow the resident time to vent feelings/needs; --approach resident in a calm friendly manner; --document interventions and resident's response; --encourage family involvement; --encourage resident to attend activities of choice; --adjust time spent in activities to resident's tolerance and attention span; --identify behavior triggers and reduce exposure to triggers; --observe and document the resident's activity and whereabouts every 30 minutes; and --obtain psychological evaluation as ordered. The resident also had a current care plan initiated on 09/30/16 and revised on 10/03/16 related to exhibiting or having the potential to demonstrate verbal behaviors related to: cognitive loss/dementia, poor impulse control and psychiatric disorder(s). The care plan goals stated the resident would demonstrate effective coping skills related to verbal behavior by next review; resident would not exhibit verbal outbursts direct toward others by next review and resident would verbalize understanding of triggers that result in poor impulse control and effective coping mechanisms. The care plan interventions included to: --Monitor medications, especially new/changed/discontinued, for side effects and resident's/patient's response contributing to verbal behaviors, including: antipsychotics, [MEDICATION NAME], opioids, benzodiazepines (recent discontinuation, omission or decrease in dose) drug interactions, adverse drug reactions, drug toxicity, or errors. --Evaluate the nature and circumstances (i.e., triggers) of the (resistive behavior) with resident/patient and family members/caregivers, e.g., provoked/not provoked, offensive, defensive, purposeful, during specific activities, involvement of others, patterned, easily startled, etc. --Discuss findings with resident/patient and family members/caregivers and adjust care delivery appropriately. --Evaluate need for Psych/Behavioral Health consult. --Refer resident to Psych/Behavioral Health provider to develop a Behavior Contract, if appropriate. --Provide all effective interventions (e.g., non-pharmacologic, pharmacologic) for behaviors and/or psychiatric disorder(s), (remove resident from environment) to assist resident/patient in controlling physical behaviors. --Encourage resident to seek staff support for distressed mood. --Approach the resident in a calm, unhurried manner; reassure as needed. --Remove resident from environment, if needed. --Gently guide the resident from the environment while speaking in a calm, reassuring voice. --Listen to resident and try to calm. Review of the following Minimum Data Set (MDS) assessments indicated Resident #103 was independent with transfers, and was non-ambulatory and mobile in his room and on the unit using a wheelchair: --Significant change MDS with an assessment reference date (ARD) of 09/26/16; --Quarterly MDS with an ARD of 08/11/16, 05/12/16, 08/20/15, and 05/20/15; and --Annual MDS with an ARD of 02/12/16. Further review of the clinical record of Resident #103 revealed General Notes, dated 07/21/15 at 2:48 a.m., documented Resident #103 approached a male nurse aide (NA), asking sexually inappropriate questions. The notes documented the NA did not respond to the resident. General Notes, dated 07/21/15 at 6:46 a.m., documented Resident #103 was talking to staff in a very sexually inappropriate manner. Review of General Notes, dated 07/23/15 at 1:35 p.m., documented the Social Worker (SW) and the former Director of Nursing spoke with the resident regarding inappropriate language used toward staff. The notes documented the resident reported he understood and he would not use inappropriate, sexual language again. There was no indication the resident's supervision was increased at that time to monitor or prevent the sexual inappropriate behavior. During interview on 10/05/16 at 9:27 a.m., the Administrator and DON revealed, on 10/29/15, staff witnessed Resident #103 put his hand in the pants of a cognitively impaired resident. The Administrator stated after the incident the physician changed Resident #103's medication. The Administrator further revealed, on 11/12/15, Resident #103 was involved in an incident of resident to resident inappropriate physical contact with a now discharged resident. Resident #103 was moved to a private room, referred to geriatric psychiatry and his plan of care updated as a result of that incident. He further revealed on 01/28/16 Resident #103 was involved in an incident of resident to resident physical contact with an alert and oriented resident who is now discharged . The Administrator and DON denied the alert and oriented discharged resident voiced or displayed any negative effect due to the incident. They stated Resident #103 was moved back into a semi private room at beginning of (MONTH) (YEAR) and remained in a semi-private room until 09/18/16. The Administrator stated Resident #103 had roommates while residing in the semi-private room, but he was unsure if any of those roommates were cognitively impaired. At the time of this interview the Administrator verified there was no implementation of specific one on one continuous supervision or increased timed supervision of Resident #103 until 09/20/16 when Resident #103 was placed on every 30 minute checks from 8:00 p.m. through 8:00 a.m. On 09/29/16 Resident #103 was placed on every 30 minute checks 24 hours/day. The Administrator stated he felt the facility staffed adequately to meet the needs/supervision of residents. During an interview with Social Worker (SW) #31, on 10/05/16 at 11:33 a.m., she verified she was informed by a NA (she did not recall name) Resident #103's roommate (Resident #146) reported Resident #103 had touched his toes and attempted to get into his bed. SW #31 stated she went and spoke with Resident #146 who verified the allegation. She stated Resident #146 was not upset and did not express fear of Resident #103. Resident #146 stated they had been friends for a long time and he did not feel it was a big deal. SW #31 stated she notified the Administrator immediately of the incident due to Resident #103 allegedly attempting to get into Resident #146's bed. SW #31 stated Resident #103 was moved to another room with an alert and oriented resident. Review of General Notes by Registered Nurse (RN) #40 dated 10/29/15 at 9:35 a.m., revealed after exiting Resident #103's room, RN #40 observed Resident #103 reaching in the front of another resident's pants. The notes documented RN #40 asked Resident #103 what he was doing and Resident #103 pulled his hands out of the other resident's pants, looked at RN #40 and said What? The notes documented RN #40 re-directed the resident to his room and advised him to keep his hands off of other residents. The notes documented RN #40 assisted the other resident to nursing station and advised the physician of Resident #103's behavior. There was no evidence Resident #103 was placed on increased supervision to prevent further inappropriate resident to resident contact. Review of General Notes, dated 11/05/15 at 11:27 a.m., revealed Resident #103 was heard using inappropriate language directed to Licensed Practical Nurse (LPN) #52 and attempted to touch the nurses bottom. The notes documented Resident #103 was redirected and re-educated on appropriate behavior, but behavior was still ongoing. Review of General Notes, dated 11/05/15 at 12:43 p.m., documented a new order was received to change the resident's antidepressant medication ([MEDICATION NAME] XR) to 75 milligrams by mouth once per day. There was no evidence the resident was provided increased supervision to prevent further inappropriate touching or verbalizations. Review of a Report of Consultation by the psychologist, dated 11/05/15, revealed the resident was documented not to have capacity. Review of Social Service Notes, dated 11/12/15 at 2:45 p.m., revealed an order received for a geriatric psychiatric consultation for Resident #103 at a local hospital, as well as a consultation with a psychologist for evaluation. Review of General Notes, dated 11/12/15 at 3:39 p.m., revealed RN #40 interviewed Resident #103's former roommate (now discharged ) as she had been advised by a staff member Resident #103 may have had inappropriate sexual contact or conversation without the former roommates consent. The notes documented Resident #103's former roommate stated about a month after he became roommates with Resident #103 he was asked by Resident #103 how big his penis was. The notes documented Resident #103 proceeded to advise his former roommate he had oral copulation with 12 to 15 men in his lifetime. The former roommate also stated that around this time he was scheduled to have a colonoscopy procedure. It was during this time, he was awakened one night by Resident #103 rubbing his bare leg and advancing toward his groin. The former roommate told Resident #103 to stop to which Resident #103 replied, But, I love you. The notes further documented the former roommate reported he told Resident #103 to stop and go away again and Resident #103 returned to his side of the room. Per the notes, the former roommate went on to report on another night around the same time he was awakened again by Resident #103 rubbing his feet. He told Resident #103 to stop and Resident #103 started kissing his former roommate's feet. The former roommate told Resident #103 to stop or he would tell the administrator and Resident #103 returned to his side of the room. The notes documented Resident #103 had not touched his former roommate since that incident. The notes further documented the former roommate stated he noticed daily when Resident #103 exited their bathroom he watched his former roommate through the cracked hinged part of the bathroom door. The former roommate stated he tried to keep his curtain pulled so that Resident #103 could not see him when he exited the bathroom. The notes documented RN #40 notified the physician, the Director of Nursing and administrator of her interview results. The notes documented Resident #103 was moved to a private room, multiple laboratory test were ordered, a geriatric psychiatry consultation and the psychologist had also been requested for consult. There was no evidence the resident's level of supervision was increased to prevent further resident to resident inappropriate and undesired contact. Review of Care Plan Evaluation Notes, dated 11/13/15 at 12:50 p.m., revealed a quarterly assessment completed for Resident #103. The notes found an order noted, on 11/05/15, to increase the resident's [MEDICATION NAME] XR to 75 mg daily. The notes indicated his care plan was reviewed and revised as needed. Review of Social Service Notes dated 11/13/15 at 12:58 p.m. revealed the Administrator, Director of Nursing (DON) and Social Worker met with Resident #103's medical power or attorney (MPOA) that same day. The notes documented the meeting was to discuss Resident #103's recent behavior which led to him being moved to a private room to protect his former roommate and also to protect Resident #103 from possible negative reactions from other resident's toward him. It was discussed the resident was scheduled to see the psychologist that weekend and he would be asked to explore with the resident the extent to which he understood why he is in a different room and make an effort to counsel the resident in regards to his behavior and to gather his recommendations for medication, ongoing counseling and possible inpatient placement. The notes documented the resident's family member advised Resident #103 now verbalized and demonstrated affection toward her (hugs, kisses, etc.) which was in stark contrast to the majority of his life. The DON advised that Resident #103 requested that morning to not have male aides work with him. Review of a Report of Consultation by the psychologist, dated 11/14/15, revealed Resident #103 had a significant increase in sexual behaviors towards male residents. Recommendations of the consultation included to, 1) remove things from the resident that appear to trigger his inappropriate sexual behavior (ISB); 2) consistently redirection to appropriate activities; 3) document any new ISB; 4) psychologist will see again within a week; 5) If #1 and #2 do not decrease ISB, approach primary care physician to increase antidepressant medication ([MEDICATION NAME]); 6) If #5 does not work, consider hormone therapy such as [MEDICATION NAME] or antiandrogens and approach psych. Review of a Report of Consultation by the psychologist, dated 11/14/15, revealed the consult documented Resident #103 had a significant increase in sexual behaviors towards male residents and staff. Review of a Psychiatric Consultation Log indicated an interview was conducted with Resident #103 on 11/16/15 due to the resident being referred for inappropriate behaviors of touching male residents and male staff. The Consultation findings documented Resident #103 asked if he was in trouble and if he was even capable. The findings documented Resident #103 had capacity to make medical decisions and that he denied inappropriate behaviors. The documentation revealed Resident #103 stated he is a Christian and at his church people shake hands and pat each other on the shoulder. He stated he was just joking and people took the behaviors the wrong way stating, I was just kidding them. They did not take it that way. I think that is why I am here. Specific recommendations for the facility were 1) Continue to set limits; 2) Continue to discuss expected behaviors; 3) monitor behaviors, and 4) Praise for positive behaviors. Review the pharmacy Consultation Report for Resident #103 from 11/01/15 through 11/30/15 revealed the pharmacist recommended the resident's [MEDICATION NAME] XR 75 mg daily for management of major [MEDICAL CONDITION] be assessed, and if appropriate consider a gradual dose reduction. The physician signed the recommendation on 11/19/15 and noted to continue use of the [MEDICATION NAME] at the current dose. The report documented patient-specific rationale describing why a gradual dose reduction attempt was likely to impair the resident's function and instability and the psych recommended increasing the [MEDICATION NAME] dose due to inappropriate sexual behaviors. Review of Resident #103's Physician & NP/PA Narrative Chief Complaint & History, dated 11/18/15 at 2:15 p.m., revealed an evaluation the of Resident #103 ' s current dose of [MEDICATION NAME]. The notes documented the resident received 75 mg and had exhibited inappropriate sexual behaviors recently and psych recommended increasing his dose. It was doubled 2 weeks ago. The notes documented the resident's behaviors appeared to have reduced and he had been placed in a private room. The Assessment/Plan & Other Information documented the resident had depression and the physician would continue his current dose of [MEDICATION NAME] at 75 mg by mouth daily and monitor his mood and behaviors. The notes documented he was not a candidate for a gradual dose reduction currently due to his behaviors, psych had agreed as well. The physician would monitor and increase the dose if needed. Review of a Report of Consultation by the psychologist, dated 11/24/15, revealed the resident was seen for a follow-up and he did not have capacity since 11/25/14. The psychologist documented he had seen the resident on several occasions and that he had a recent inappropriate sexual behavior incident that was uncharacteristic of him. The psychologist documented Resident #103 did not appear to recall his behavior and that his [MEDICATION NAME] was increased on 11/12/15 with appears to have had positive results. The psychologist recommendations included 1) If approved by primary care physician, continue [MEDICATION NAME]; 2) Engage in hobbies, activities to keep occupied; 3) he can probably move back to a semi-private room. Staff should monitor resident closely for first 30 days (i.e. 15 minute visual checks); and 4) If behavior returns, psychologist will see again. There was no evidence of every 15 minute checks completed on Resident #103 as recommended by the psychologist. Review of Social Service Notes, dated 01/04/16 at 3:50 p.m., revealed Resident #103 was offered to move from bed 302A to 302B to be near the window. Resident #103 accepted and was assisted to move to 302B by staff. There was no evidence the resident was to have increased supervision at that time if he were to have a roommate while he occupied the semi-private room. Review of General Notes, dated 01/14/16 at 9:45 p.m., found at approximately 7:15 p.m. Resident #103 was propelling in his wheelchair down the 200 hallway towards another resident's room (resident now discharged ) when he attempted to open the other resident's door. The notes documented the nurse interfered and informed Resident #103 he could not go into that room, that if the other resident wanted a visitor then he would seek him out. The notes documented Resident #103 got angry and stated the other resident had invited him to his room at dinner time. The nurse again stated to Resident #103 if the other resident wanted a visitor he would come seek him. Resident #103 appeared very agitated and yelled, Who are you?! and, Are you the boss?! The notes documented the nurse re-educated Resident #103 again that he was not allowed in the room and he finally went back to his own room. General Notes, dated 01/15/16 at 2:56 p.m., documented Resident #103 again attempted twice to go in the other resident's room (same now discharged resident) by attempting to open the door to room. The notes documented Resident #103 was instructed to please go to his room or another area of the facility. The notes documented Resident #103 stated he was invited to the other resident's room. The notes document the other resident was interviewed and stated no invitation was made. The notes documented Resident #103 stated he was tired of you people treating me like dirt, but he complied and went back to his room. General notes indicated staff were to continue to monitor and re-educate the resident as necessary. There was no documentation of increased supervision of Resident #103 to prevent any further attempts of entrance to the other resident's room. General Notes, dated 01/15/16 at 5:15 p.m., documented Resident #103 was found in the other resident's room (same now discharged resident) by a N[NAME] The notes documented Resident #103 was asking the other resident for his address. The NA then asked the other resident if he wanted Resident #103 to have his address to which the other resident stated no. The notes documented the NA then tried to redirect Resident #103 out of the resident's room and Resident #103 told the NA, Leave me alone you [***] ! and as the NA was escorting Resident #103 out of the room he swung and tried to hit her. The notes documented the nurse and nursing supervisor tried to talk to Resident #103 and redirect and Resident #103 stated, You are a[***]y supervisor! The notes documented Resident #103 was redirected to his room shouting, I will have your jobs!. The physician was notified and ordered an antipsychotic medication ([MEDICATION NAME] 5 mg) intramuscularly once at that time for combative behavior and agitation. There was no documentation of increased supervision of Resident #103 to prevent any further uninvited entrance to the other residents rooms. Review of General Notes, dated 01/18/16 at 3:15 p.m., revealed a new order to change Resident #103's [MEDICATION NAME] to 100 mg once daily. Review of Physician & NP/PA Narrative Chief Complaint & History, dated 01/19/16 at 2:35 p.m., revealed the resident was seen that day due to a new condition. He had been more combative lately and had more inappropriate sexual behaviors and dementia symptoms. The Assessment/Plan and Other Information documented dementia-with behaviors were recently uncontrolled, and to increase his [MEDICATION NAME] to 100 mg by mouth daily and monitor. Add agents as needed. Review on 10/05/16 revealed a General Late Entry Notes, dated 01/28/16 at 3:40 p.m., documented Resident #103 was following another male resident to his room and was asked and re-directed to his room on another hall. The note documented, less than 5 minutes later, Resident #103 went into another resident's room in his wheelchair and the nurse was observing. The notes documented Resident #103 was gently rubbing the back and neck of the resident in the room and the resident stated. No, no, no, and was trying to get away from Resident #103. The nurse then removed Resident #103 from that room and hall, and re-directed him to the hall he resided on. The notes documented Resident #103 raised his voice yelling, Don ' t tell me what I can and don ' t tell me what I can and can ' t do! The incident was reported to the DON. There was no indication Resident #103's level of supervision was increased to prevent further resident to resident physical contact. General Notes dated 01/29/16 at 2:26 p.m. documented Resident #103 followed another male resident around the facility and was wanting to know if he could be his roommate. The note revealed Resident #103 wanted to know if he could go to his room with him. The notes stated Resident #103 was redirected four times that shift. General Notes dated 01/29/16 at 2:52 p.m. found Resident #103 sticking his finger down his throat and gagging in hallway and when asked if he was okay, Resident #103 stated, Yeah can I go to his room now? The notes stated Resident #103 was referring to another male resident and that Resident #103 was redirected. General Notes dated 04/11/16 at 6:50 a.m. revealed while a former Licensed Practical Nurse (LPN) standing at the nursing station with her back facing towards the television, Resident #103 came up behind her and ran the fingers of his right hand across the nurse's buttocks. The notes stated when the nurse asked the resident about it he first denied it and then after a few minutes he apologized. Review of a Physician Determination of Capacity form, dated 05/10/16, revealed Resident #103 lacked sufficient mental or physical capacity to appreciate nature and implication of health care decisions. The document indicated the [DIAGNOSES REDACTED]. The nature of the incapacitation was indicated as evidenced by cognitive loss, inappropriate answers to questions and inability to understand or make medical decisions. The expected duration of the resident's incapacity was indicated as long term. Review of General Notes, dated 06/01/16 at 2:54 p.m., revealed orders were written for Resident #103 to have a consultation with the psychiatrist due to predatory behavior. A Report of Consultation, dated 06/3/16, documented the psychologist saw Resident #103 on several occasions due to similar concerns, most recent 12/22/15. The psychologist documented inappropriate sexual behavior (ISB) is not uncommon with dementia. Resident made inappropriate comments to residents. Recommendations included to redirect the resident; engage the resident in daily activities to keep him occupied; see if primary care physician (PCP) will increase his [MEDICATION NAME] if other interventions don't help and if those interventions don't work, and psychologist will see Resident #103 again. Review of General Late Entry Notes, dated 08/26/16 at 12:09 p.m., revealed male Licensed Practical Nurse (LPN) #55 was passing morning medications at 8:00 a.m. when Resident #103 repeatedly stated, Hey good looking to the nurse. At 8:30 a.m., while administering medications to Resident #103, Resident #103 made an attempt to grab LPN #55's crotch and stated, I bet you have big one down there. Can I shave it? We can shave each other. The notes documented Resident #103 was told to cease his behavior. LPN #55 further documented at 8:45 a.m., again while passing medications, Resident #103 wheeled out into hall and grabbed the hall nurse's buttocks. The DON and family was notified. Review of General Late Entry Notes dated 08/26/16 at 2:15 p.m., revealed the DON and Assistant Director of Nursing (ADON) #36 met with Resident #103 about him saying sexual remarks and trying to touch LPN #55. The notes documented Resident #103 insisted that he meant nothing by it and that he was just joking around. The DON documented he explained to Resident #103 that LPN #55 had come to him about this and that he did not find these actions funny. The DON documented Resident #103 assured him he would not speak to the nurse in such a manner again and that he would not try to touch him either. The DON thanked Resident #103 for his cooperation. No acute distress was noted. Review of General Notes, dated 09/18/16 at 3:08 p.m., by Social Worker #31 revealed she was approached by a NA who stated Resident #103's roommate alleged Resident #103 was inappropriate with him. SW #31 documented she interviewed Resident #103's roommate who stated Resident #103 played with his toes and attempted to get in bed with him. The roommate indicated Resident #103 had displayed inappropriate behaviors. SW #31 further documented Resident #103 was transitioned to a different semi-private room. SW #31 documented she told Resident #103 why he was being transitioned to a new room and he voiced understanding. He was introduced to new roommate. Social Service Notes dated 09/19/16 at 8:40 a.m. documented a Behavioral Health Referral was made due to an allegation that Resident #103 was inappropriate toward his roommate. Review of General Notes, dated 09/20/16 at 3:21 p.m., revealed the licensed social worker (LSW) from the local hospital behavior science department came to the facility to evaluate Resident #103 but he was sleeping. The notes document she would return that evening or the next day to evaluate Resident #103. General Notes, dated 09/20/16 at 3:36 p.m., documented Resident #103 was assessed by the licensed social worker from the local hospital behavior science department for recent behaviors. Review of the licensed social worker's psychiatric consultation log revealed Resident #103 was referred due to sexually inappropriate behaviors and was interviewed on 09/20/16. The consultation findings documented Resident #103 exhibited sexually inappropriate behaviors and was moved to another room. The documentation stated Resident #103's new roommate was oriented and that Resident #103 sleeps most of the day and is then up and out at night. He was reported by a peer that he touched him. Per staff report Resident #103 stated this did occur. The LSW documented the nurse assisted in attempt to wake Resident #103 and he did not wake up. Recommendation was for mobile team follow up as needed. Specific recommendations to the facility were to consider reviewing the resident's medications, set limits with him and continue to monitor closely. Review on 10/06/16 of another psychiatric consultation log by the LSW from the local hospital behavioral department also with an interview date of 09/20/16, revealed the findings of the interview documented Resident #103 stated he was sorry. He stated it would not happen again. He stated it is over with and that his roommate is not his type. He stated that it had not happened before. LSW documented it was charted he had past events. The LSW documented in the findings that Resident #103 stated he could control his feelings. Specific recommendations for the facility were to attempt to change the resident's nights and days; attempt to increase his activities and continue to monitor. Review of General Notes, dated 09/22/16 at 9:43 a.m., revealed an Interdisciplinary Team (IDT) Meeting was held. The notes documented Resident #103 was seen by the LSW from the local hospital behavioral science department for evaluation related to increased inappropriate behavior. The notes document the med psych will not accept Resident #103 as a patient offering the facility a suggestion to have the psychologist visit the resident. Review on 10/05/16 of a Report of Review of a Report of Consultation, dated 09/27/16, by the psychologist documented Resident #103 was polite and cooperative and tearful. The psychologist documented Resident #103 had dementia with depression and behaviors. Recommendations were to prescribe an anti-depressant, if approved by the physician and not currently prescribed; to keep the resident engaged on good events and activities appropriate for his level of impairment and if the behaviors return, redirect and call the psychologist to reassess the resident. Review of a Physician Determination of Capacity dated 09/27/16 revealed the psychologist certified the Resident #103 lacked sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. The documentation indicated the nature of the incapacitation was evidenced by cognitive loss, inappropriate answers to questions and inability to understand or make medical decisions. The expected duration of the incapacity was indicated as long term. Review of General Notes, dated 09/27/16 at 3:06 p.m., documented a report of consultation from the psychologist recommended an anti-depressant, if the resident was not already on one. The notes documented the physician was aware and the resident was currently on an anti-depressant. No new orders were noted. Review of Care Plan Evaluation Notes, dated 09/28/16 at 9:06 a.m., revealed a significant change assessment completed for Resident #103 and he had no behaviors noted/documented during the 7 day look back for this assessment. However, he had behaviors of sexual inappropriateness with nursing staff and previous roommate since last review on 08/11/16. His care plan was reviewed and revised as needed. The notes stated continue with plan of care. Review of Social Service Late Entry Notes, dated 09/29/16 at 2:26 p.m., revealed SW #31 was told Resident #103 had made inappropriate advances to another resident. SW #31 interviewed the other resident who stated Resident #103 kissed the back of his hand, stroked his beard and asked him to come to his room later for a kiss. The other resident stated he didn't feel violated. SW #31 documented she brought Resident #112 to her office to discuss this allegation and while pushing the resident's wheelchair to the front of the facility Resident #103 asked this same male resident to come see him in his room. Resident #103 told the other male resident he had the room to himself and was lonely. The other resident told him he wasn't interested. SW #31 documented that within minutes Resident #103 asked the same resident again to come see him in his room. SW #31 and th (TRUNCATED)",2020-02-01
4937,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,157,D,1,0,1MMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to promptly notify the physician of a resident's change of condition and/or when the physicians' orders directed facility staff to notify the physician for three (3) of twelve (12) sampled residents. Resident #75's scheduled dose of insulin was held without notification and/or the approval of the attending physician. Nurses held Resident #37's scheduled dose of insulin on multiple occasions, but failed to notify the physician the medication was held and/or to gain approval for holding the medication. For Resident #10 the facility failed to notify the physician on several occasions when her blood sugar was greater than 300 as directed by the resident's physician order. Resident Identifiers: #10, #37, and #75. Facility Census: 72. Findings include: a) Resident #75 A review of Resident #75's medical record at 9:30 a.m. on 05/12/16 found the following physician orders for insulin used to treat her [DIAGNOSES REDACTED]. Humalog Solution Inject as per sliding scale if: - 111-140 = 1 unit, - 141-170 = 2 units, - 171-200 = 3 units, - 201-230 = 4 units, - 231-260 = 5 units, - 261 - 290 = 6 units, - 291 - 320 = 7 units, - 321 - 350 = 8 units, - 351 - 380 = 9 units, and - 381 - 400 = 10 units - notify physician if less than 60 or greater than 400. This medication was scheduled at 6:00 a.m., 11:00 a.m., 4:00 p.m., and 10:00 p.m. This order had a start date of 09/28/15. [MEDICATION NAME] N Suspension Inject 15 units subcutaneously one time a day related to DM II. The scheduled time for administration was 6:00 a.m. This order had a start date of 09/26/15. When readmitted from the hospital on [DATE], the time of this administration changed to 10:00 a.m. On 04/01/16, the medication administration time was changed back to 6:00 a.m. [MEDICATION NAME] N Suspension Inject 10 units subcutaneously at bed time related to DM II. This medication scheduled at 10:00 p.m., had an order start date of 09/26/15. Review of the medication administration records (MAR) from 09/26/15 through present found Resident #75's [MEDICATION NAME] N scheduled at 6:00 a.m., was held on: - 02/13/16, - 02/15/16, and - 02/17/16. Further review of the Resident #75's medical record found no reason why her scheduled dose of insulin was held on these occasions. The order had no physician ordered low parameter to indicate the physician wanted the medication held. There was also no evidence the nurse had called the physician and notified him that she held Resident #75's scheduled insulin and/or to obtain approval for holding the insulin. b) Resident #37 A review of Resident #37 medical record at 1:00 p.m. on 05/12/16 found this [AGE] year-old female, admitted to the facility in 2012, was in the hospital from 08/07/15 through 08/10/15. Review of Resident #37's MARs from 08/10/15 through 05/12/16 found the resident had a physician's order for, Fingerstick blood sugar in the morning for [DIAGNOSES REDACTED] notify physician if greater than 300 or less than 70. This order had a start date of 08/28/12. Upon Resident #37's readmission to the facility on [DATE], the physician ordered the following insulin regimen to control her DM II: - [MEDICATION NAME] R 5 units SQ three times a day at 6:00 a.m., 11:00 a.m., and 4:00 p.m. This medication began on 08/11/15. - Accucheck four times a day with scale insulin coverage with [MEDICATION NAME] R if: - 111-140 = 1 unit, - 141-170 = 2 units, - 171-200 = 3 units, - 201-230 = 4 units, - 231-260 = 5 units, - 261 - 290 = 6 units, - 291 - 320 = 7 units, - 321 - 350 = 8 units, - 351 - 380 = 9 units, and - 381 - 400 = 10 units notify physician if less than 60 or greater than 400. Review of Resident #37's MAR for 09/2015 found LPN #5 held Resident #37 scheduled dose of [MEDICATION NAME] R insulin at 6:00 a.m. on: - 09/15/15 - Blood sugar (BS) 78, - 09/16/15 - BS 78, and - 09/17/15 - BS 109 The only indication in the medical record as to why LPN #5 held the insulin was on 11/15/15 by LPN #5. LPN #5 wrote on the back of the MAR indicated [REDACTED]. Although the resident's blood sugar was above the physician specified parameter to hold the insulin, there was no evidence LPN #5 contacted the physician to obtain an order to hold the insulin, nor did she notify the physician that she held the insulin. Review of Resident #37's 10/2015 MAR found LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. Again, there was no evidence LPN #5 contacted the physician to obtain an order to hold the insulin, nor did she notify the physician that she held the insulin on: - 10/09/15 - BS 95, - 10/10/15 - BS 78, - 10/15/15 - BS 87, and - 10/27/15 (BS 86) Review of Resident #37's 11/2015 MAR found LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. There again was no evidence LPN #5 contacted the physician to obtain an order to hold the insulin, nor did she notify the physician that she held the insulin on: - 11/01/15 - BS 84, - 11/02/15 - BS 90, - 11/11/15 - BS 91, - 11/12/15 - BS 92, - 11/13/15 - BS 106, and - 11/24/15 - BS 94. Review of Resident #37's 12/2015 MAR found LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. There was no evidence contained in the medical record which indicated why this medication was held or that the physician was notified and/or gave approval to hold the medication to hold the resident's insulin for a blood sugar of 93 on 12/08/15. Review of Resident #37's 01/2016 MAR found LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. There was no evidence contained in the medical record indicating why this medication was held or that the physician was notified and/or gave approval to hold the medication on: - 01/23/16 - BS 86, and - 01/24/16 - BS 74 Review of Resident #37's 02/2016 MAR found LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. There was no evidence contained in the medical record of the reason why this medication was held or that the physician was notified and/or gave approval to hold the medication on: - 02/08/16 - BS 84, - 02/11/16 - BS 72, - 02/12/16 - BS 82, - 02/16/16 - BS 78, - 02/18/16 - BS 87, - 02/21/16 - BS 74, - 02/22/16 - BS 94, and - 02/25/16 - BS 98 Review of Resident #37's 03/2016 MAR found LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. There was no evidence contained in the medical record which indicated why this medication was held or that the physician was notified and/or gave approval to hold the medication on: - 03/19/16 - BS 97, and - 03/20/16 - BS 100 Review of Resident #37's 04/2016 MAR found LPN #21 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. on: - 04/11/16 - BS 92, - 04/13/16 - BS 89, and - 04/16/16 - BS 99 LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. on: - 04/17/16 - BS 86 Registered Nurse (RN) #53 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. on: - 04/19/16 - BS - 102 There was no evidence contained in the medical record which indicated why this medication was held or that the physician was notified and/or gave approval to hold the medication. c) Resident #10 Review of Resident #10's medical record at 9:45 a.m. on 10/16/15 found this resident most recently readmitted to the facility on [DATE] after a hospital stay. Prior to this hospitalization Resident #10 had remained in the facility since 12/30/14 as a long-term care resident. Review of Resident #10's [DIAGNOSES REDACTED]. Both [DIAGNOSES REDACTED]. Review of Resident #10's physician orders for 08/01/15 through 05/16/16 found the following physician orders pertaining to the management of her DM II, -- [MEDICATION NAME] Solution inject as per sliding scale if: - 111-140 = 1 unit, - 141-170 = 2 units, - 171-200 = 3 units, - 201-230 = 4 units, - 231-260 = 5 units, - 261 - 290 = 6 units, - 291 - 320 = 7 units, - 321 - 350 = 8 units, - 351 - 380 = 9 units, and - 381 - 400 = 10 units - notify physician if less than 60 or greater than 400 four times a day before meals and at bedtime. This had an order date of 04/28/16. -- Fingerstick blood glucose two times a day notify physician if less than 70 and greater than 300. This had a start date of 04/30/15 and remained in effect until her readmission to the facility on [DATE]. Review of Resident #10's MARs for 08/01/15 through 05/16/16 found the following occasions when Resident #10's blood sugars were greater than 300 and required notification of the physician as directed by the physician's order dated 04/30/15. -- 04/19/16 at 6:00 a.m. her blood sugar was 382. -- 03/03/16 at 4:00 p.m. her blood sugar was 341. -- 03/10/16 at 4:00 p.m. her blood sugar was 364. -- 03/31/16 at 6:00 a.m. her blood sugar was 401. -- 02/21/16 at 6:00 a.m. her blood sugar was 305. -- 12/27/15 at 4:00 p.m. her blood sugar was 384. -- 11/02/15 at 4:00 p.m. her blood sugar was 319. -- 10/26/15 at 4:00 p.m. her blood sugar was 430. -- 09/04/15 at 4:00 p.m. her blood sugar was 344. -- 09/25/15 at 4:00 p.m. her blood sugar was 425. There was no evidence in the medical record to indicate the physician was notified of Resident #10's elevated blood sugars. Also, on 02/26/16 at 6:00 a.m. Resident #10's blood sugar was 318. There was no evidence the nurse notified the physician of the resident's elevated blood sugar at that time. At 4:00 p.m. when checked again per physician order, her blood sugar was even higher at 545. It was only after obtaining this blood sugar that the facility contacted the physician and obtained an ordered for a onetime dose of 14 units of Humalog. d) Staff Interviews Relating to Diabetic Management During an interview with RN #51 at 11:30 a.m. on 05/12/16, when asked how the nurses determined whether or not to hold a resident's scheduled insulin if there was not a physician established parameter for the order. She said it was a nursing judgement. She stated it was very discretionary depending on a lot of things like the resident's blood sugar, if the resident ate, and what the resident ate. She stated the nurses knew the residents, and how their blood sugars behaved, so it was at the nurse's discretion whether to hold the insulin. She indicated if a resident was not to have anything by mouth because of a scheduled procedure they would not give any of diabetic medications including insulin. She indicated that they learned about this in nursing school and it was really just up to the nurse. When asked if the nurse should contact the physician, she stated, No it is a nursing judgement. An interview with RN #53 at 1:58 p.m. on 05/12/16 found that if she made the decision to hold the resident's insulin, she would call the doctor. She stated that it would depend on the resident's blood sugar and if the resident had eaten and what the resident had eaten, but if she did not feel comfortable administering the insulin she would call and notify the physician so the physician could make the final decision. During an interview at 2:05 p.m. on 05/12/16, when asked about holding a resident's scheduled insulin when there was no physician ordered low parameter, the Director of Nursing (DON) said that to hold or not to hold a resident's insulin was a nursing judgement. He did state however, the expectation would be that the nurse would call the provider and notify them that they felt the insulin should be held and why and let the provider give the final answer on whether or not to hold the resident's insulin. He stated the nurse should document the conversation with the provider in the medical record. e) At 2:45 p.m. on 05/16/16, during a discussion of these findings we with the DON, Administrator, and a Registered Nurse (RN) #102, a facility consultant, they were asked to provide any additional information available. At the time of exit at 4:30 p.m. on 05/18/16, with the Director of Nursing (DON) the facility provided no further information. .",2019-05-01
4938,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,166,E,1,0,1MMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the resident council minutes, review of grievance concern forms, and staff interview, the facility failed to make prompt efforts to resolve grievances. Residents attending the council meetings complained about staffs' failure to answer call lights in a timely manner. In addition to the council meetings, review of the grievance concern forms found two (2) residents complained, on separate occasions, regarding answering call lights in a timely manner. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: #48 and #73. Facility census: 72. Findings include: a) Resident council minutes Review of the resident council minutes from the 11/02/15 meeting found 10 members, (whose names were not listed) attended the meeting. The council meeting minutes addressed a concern expressed at the meeting, .Call lights not being answered timely during meals and shift change The Director of Nursing (DON) addressed the facility's response to the complaint. The date the concern was addressed by the DON was not documented on the grievance form. The DON's response to the concern was, Nursing will randomly monitor and document timely of call lights to include monitoring during meal times and shift change. During the 01/26/16, resident council meeting, the resident's again complained about call lights not being answered timely. The response form, completed by the DON on 01/26/16, was, Nursing will randomly monitor call lights and nurse will validate on all shifts. At 12:18 p.m. on 05/16/16, Activity Directory #36, who completed the minutes of the resident council meetings, confirmed she never received the copies of the audits of the call lights that were to be completed by the DON. At 12:26 p.m. on 05/16/16, the DON confirmed the only call light audits completed, were those he completed on 02/09/16 and 02/18/16. The audit for 02/09/16 noted observation of call lights activated from 2:17 p.m. to 2:40 p.m. The audit for 02/18/16 noted observation of call lights activated from 1:10 p.m. through 1:41 p.m. The DON confirmed the call light audits were not completed on all three shifts, at shift change and during meal times as indicated in the resident council minutes. b) Resident #73 Record review on 05/10/16 at 11:30 a.m., found the resident was admitted to the facility on [DATE]. Review of the Grievance/Concern forms found Resident #73's spouse voiced a concern on 01/18/16 stating call lights were not answered timely on evening shift after dinner, between 6:00 p.m. and 8:00 p.m. The action taken to investigate the grievance concern was, Evening shift staff re-educated on call light timeliness and evening shift supervisor to monitor call lights. The grievance/concern form noted the facility's corrective action was, SW (social worker) followed up with (name of resident) on 01/21/16 and she reports call lights are better. c) Resident #48 Record review found the resident was admitted to the facility on [DATE]. Review of the grievance concern forms found Resident #48 voiced a concern on 04/22/16 stating call lights were not answered timely on evening shift after dinner, a few nights ago. The action taken to investigate the grievance concern was, Evening shift supervisor to monitor call lights. The grievance/concern form noted the facility's corrective action was, SW (social worker) followed up with (name of resident) on 04/25/16 and 04/26/16, he reports everything is much better. d) At 3:25 p.m. on 05/10/16, the administrator provided a copy of the nursing supervisors working on evening shift from 01/18/16 through 01/23/16. RN #50 was listed as the evening shift supervisor working on 01/19/16, 01/20/16, and 01/21/16 (the period of the resident's grievance). An interview with RN #50 at 3:30 p.m. on 05/11/16, found he was unaware Residents #48 and #73 had made any complaints about the timeliness of the call lights being answered. RN #50 said he did not complete any written audits regarding call lights during that period. He did acknowledge his job required keeping an eye on the care provided to residents and a part of this assignment included ensuring call lights were answered. An interview with Social Worker #93 at 5:45 p.m. on 05/12/16, found she did not have any evidence the evening shift supervisor monitored the call lights. She stated the director of nursing (DON) would have taken care of this issue. At 12:26 p.m. on 05/16/16, the DON confirmed he did not have any audits of call light monitoring for Resident #73 during the period of 01/18/16 through 01/23/16. e) Although the response on the form for Resident #72 identified staff were educated about call lights in (MONTH) (YEAR), the facility failed to monitor the effectiveness of the education. The facility also failed to complete monitoring on evening shift as the identified on the grievance forms for Residents #48 and #73 to ensure staff continued to answer call lights in a timely manner.",2019-05-01
4939,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,225,D,1,0,1MMH11,"> Based on review of the facility's reportable allegations of abuse, neglect, and misappropriation of resident's property, staff interview, review of the Abuse / Neglect Reporting Requirements for West Virginia Nursing Homes and Nursing Facilities, and facility policy review, the facility failed to report an allegation of abuse to the appropriate State agencies immediately in accordance with State law. This was true for one (1) of six (6) reported allegations reviewed. Resident identifier: #23. Facility census: 72. Findings include: a) Resident #23 Review of the facility's reportable allegations of abuse/neglect and misappropriation of resident property on 05/10/16 at 9:25 a.m., found an alleged incident reported to the Nurse Aide Registry on 02/11/16. Resident #23's daughter stated her father's roommate told her, That black guy took him to the bathroom last night and slammed him down and talked to him like a dog. The staff member knocked his glasses off and stepped on them and his hearing aid was on the floor. The facility reported the allegation to the Nurse Aide Registry on 02/11/16 and listed the perpetrator as Unknown. The nurse aide reporting form (NAR-1) requires the facility to list the name of the alleged perpetrator, the registered nurse aide's eval-code (evaluation code), the home address, and telephone number. Therefore, an unknown perpetrator was not required to be reported to this agency. The facility's investigation found two (2) black male nurse aides worked on the day the alleged incident occurred. One (1) staff member worked on the afternoon shift and the other on the night shift. The facility's investigation found the black male nurse aide working on the afternoon shift did not work on Resident #23's hallway and this employee had no contact with the resident. The second nurse aide provided the following statement on 02/13/16: I did not see (name of resident's) glasses in the floor and accidentally stepped on them. I tried to repair them unsuccessfully. I tried to find (name of resident's) hearing aide as well. While providing care to (name of resident) I had to speak loudly in order for him to hear me because he didn't have his hearing aide at the time and he was asking about his hearing aide. It probably sounded like I was yelling at him but he couldn't hear me otherwise. The Abuse / Neglect Reporting Requirements for West Virginia Nursing Homes and Nursing Facilities, revised (MONTH) 2011, requires, If the alleged perpetrator is suspected to be a nurse aide, but the identity of this individual is unknown, this allegation is to be reported to OHFLAC's (Office of Health Facilities Licensure and Certification) nursing home program. Allegations of resident abuse, neglect, and misappropriation of resident property, where the alleged perpetrator is a nurse aide whose identity is known, are to be immediately reported to OHFLAC's Nurse Aide Program and not to OHFLAC's nursing home program When initially reported, the facility should have reported the allegation to OHFLAC's nursing home program. When the facility discovered the identity of the nurse aide, the facility should have reported the nurse aide to the Nurse Aide Registry. An interview with Social Worker (SW) #83, at 11:10 a.m. on 05/10/16, confirmed the facility never reported the incident to OHFLAC. Once the investigation revealed the identity of the nurse aide, the facility did not report the name of the nurse aide to the Nurse Aide Registry. On the morning of 05/11/16, SW #83 provided a copy of the reportable allegation involving Resident #23, indicating the nurse aide was reported to the nurse aide registry on 05/10/16, after surveyor intervention. The facility's policy, entitled Abuse Prohibition, directs: .6.2.1.2 If the alleged perpetrator is a nurse aide whose identity is known, report it via fax to OHFLAC's Nurse Aide Program",2019-05-01
4940,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,244,E,1,0,1MMH11,"> Based on review of the facility's resident council meeting minutes and staff interview, the facility failed to ensure grievances voiced by the group regarding staff answering call lights, which affected resident care and life at the facility, were acted upon. This had the potential to affect more than a limited number of residents. Facility census: 72. Findings include: a) Review of the resident council minutes Review of the resident council minutes from the 11/02/15 meeting found 10 members (whose names were not listed) attended the meeting. The council meeting minutes addressed a concern expressed at the meeting, .Call lights not being answered timely during meals and shift change The Director of Nursing (DON) provided the facility's response to the complaint. The grievance forms did not identify the dates the DON addressed the residents' concerns. The DON's response to the concern was, Nursing will randomly monitor and document timely of call lights to include monitoring during meal times and shift change. During the 01/26/16 resident council meeting, the residents again complained staff did not answer call lights timely. The response form completed by the DON on 01/26/16, noted, Nursing will randomly monitor call lights and nurse will validate on all shifts. At 12:18 p.m. on 05/16/16, Activity Director #36, who transcribed the minutes and chaired of the resident council meetings, confirmed she never received the copies of the audits of the call lights the DON was to complete. At 12:26 p.m. on 05/16/16, the DON confirmed the only call light audits he completed were on 02/09/16 and 02/18/16. He said his audits showed the facility did respond timely to call lights. The audit for 02/09/16, noted observation of call lights activated from 2:17 p.m. to 2:40 p.m., or 23 minutes. The audit for 02/18/16, noted observation of call lights activated from 1:10 p.m. through 1:41 p.m., or 31 minutes. The DON confirmed he did not complete the call light audits on all three (3) shifts, at shift change, and during meal times as indicated in the resident council minutes.",2019-05-01
4941,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,272,D,1,0,1MMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the Resident Assessment Instrument (RAI) Manual, and staff interview, the facility failed to ensure the minimum data set (MDS) assessment accurately reflected a resident's condition. Resident #73's assessment identified the resident as having no bowel movements for the entire 7 days of assessment, and failed to identify the resident had [DIAGNOSES REDACTED]. This was true for one (1) of nine (9) residents sampled in the Complaint Survey ending on 05/18/16. Resident identifier: #73. Facility census: 72 Findings include: a) Resident #73 1. Medical record review, on 05/11/16 at 11:15 a.m., found that according to the resident's admission MDS, with an assessment reference date (ARD) of 01/18/16, the resident did not have a bowel movement for the entire 7 day look back period. Review of the admission nursing assessment completed on 01/15/16, by Registered Nurse (RN) #53, found the resident had a bowel movement on 01/14/16. 2. The active [DIAGNOSES REDACTED].#73 had no fractures. Review of the discharge summary from the hospital dated 01/14/16, found results of a radiology report which identified numerous fractures of the resident's left temporal and parietal bones (bones that are part of the skull). These fractures continued to affect the resident's care needs at time of her admission. Additionally, the admission MDS did not identify the resident had had a feeding tube in the last 7 days while not a resident, or that the resident was on a mechanically altered diet. Review of the hospital discharge summary revealed Resident #73 was to receive a Dysphagia Puree diet with nectar thickened liquids (a diet with thickened liquids that are easier and safer for individuals with swallowing problems) and if resident did not consume 50% of diet, to give Two-Cal HN 240 milliliters (ml) bolus through the feeding tube. During an interview on 05/12/16 at 11:08 a.m., after reviewing the resident's discharge summary and admission assessment with Registered Nurse (RN) #2, MDS coordinator, she acknowledged the identified assessment errors were incorrect and immediately made corrections.",2019-05-01
4942,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,280,D,1,0,1MMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to revise the care plan of one (1) of nine (9) residents whose care plans were reviewed, when [MEDICAL TREATMENT] increased from three (3) days a week to four (4) days a week due to fluid overload. Resident identifier: #48. Facility census: 72. Findings include: a) Resident #48 Record review on 05/11/16 at 3:00 p.m. found this [AGE] year-old male, admitted to the facility on [DATE], received [MEDICAL TREATMENT] at an outpatient [MEDICAL TREATMENT] center for a [DIAGNOSES REDACTED]. Review of the resident's current care plan, revised on 04/25/16, found the problem: Resident exhibits or is at risk for impaired renal function and is at risk for complications related to [MEDICAL CONDITION] receiving [MEDICAL TREATMENT]. The goals associated with this problem were: [MEDICAL TREATMENT] access will remain patent through next review. Resident will not experience any complications related to chronic insufficiency through next review. Approaches included: Resident has [MEDICAL TREATMENT] on Monday, Wednesday, Friday at (name of [MEDICAL TREATMENT] center). Pick up time 10:00 a.m. At 9:36 a.m. on 05/17/16, review of the [MEDICAL TREATMENT] communication book for Resident #48 with the director of nursing (DON) found the book contained a progress note from the [MEDICAL TREATMENT] center dated 04/26/16, In order to prevent fluid overload patient is to run [MEDICAL TREATMENT] 4 treatments per week. Patient to run M, W, F (Monday, Wednesday, Friday) at 11:30 a.m. and Saturdays at 5:30 a.m. beginning on Saturdays 04/30/16 The DON was unsure whether the resident had attended [MEDICAL TREATMENT] on Saturdays. The DON confirmed, through fax communication with the [MEDICAL TREATMENT] center, the resident had received [MEDICAL TREATMENT] on Saturdays, beginning 04/30/16 and was continuing to receive [MEDICAL TREATMENT] on Saturdays. At 1:09 p.m. on 05/17/16, the DON confirmed the facility had not updated the resident's care plan to include the addition of [MEDICAL TREATMENT] treatments on Saturdays with a pick up time 5:30 a.m., in addition to Monday, Wednesday, and Friday, with a pick up time of 11:30 a.m.",2019-05-01
4943,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,282,E,1,0,1MMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, and resident interview, the facility failed to ensure qualified staff provided care in accordance with each resident's care plan for five (5) of nine (9) residents whose care plans were reviewed. The facility failed to follow the care plan for Resident #76 in regards to treating the resident's pain. For Resident #48, the facility failed to follow the resident's care plan to prevent choking hazards. The facility also failed to follow Resident #48's care plan for constipation, and care of the port-a-cath (a central venous catheter inserted in the chest used for [MEDICAL TREATMENT] treatment). For Resident #8, the facility failed to follow the care plan for use of a [MEDICAL CONDITION] (continuous positive airway pressure) machine. The facility failed to follow the care plans for Residents #37 and #10 for management of diabetes. For Resident #10, the facility failed to follow the care plan for use of an antihypertensive (medication to lower blood pressure) medication and a cardiac medication. Resident identifiers: #76, #48, #8, #37, and #10. Facility census: 72. Findings include: a) Resident #76 Medical record review at 8:30 a.m. on 05/11/16, revealed a [AGE] year-old female admitted to the facility on [DATE] from a local hospital on [DATE], after falling at home. While at the hospital, she underwent surgery for [REDACTED]. The wound measured 28 centimeters (cm) x 0.1 cm x 0.1 cm. The facility physician deemed the resident to have the capacity to make medical decisions on 01/20/16. Review of the resident's care plan found the problem: Resident exhibits or is at risk for alterations in comfort related to surgical-post-op fracture of ____. (The care plan problem failed to identify the location of the fracture). The goal associated with this problem was: Resident will not experience pain X (times) ____days. (The number of days was not completed.) Approaches included: - Medicate resident for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated. - Monitor for non-verbal signs/symptoms of pain and medicate as ordered. - Complete pain assessment per protocol. Upon admission to the facility, the resident was ordered Tylenol 650 mg (milligrams) every 6 hours as needed for pain. Review of the pain management flow sheet found the following: -- On 01/20/16 at 6:00 a.m., Tylenol 650 mg was administered for a pain rating of 8, indicating severe/horrible pain. The pain management flow sheet indicated the non-pharmacological intervention of repositioning was provided and the resident's pain decreased to a 2 (mild pain) at 7:00 a.m. -- On 01/21/16 at 2:00 p.m. the resident rated her pain as 8. The resident was repositioned and at 3:00 p.m., the resident rated her pain as 1, indicating mild pain. -- On 01/22/16 at 10:00 a.m., the resident rated her pain as a 10, indicating excruciating pain. After repositioning, the resident rated her pain as a 10 at 10:50 a.m. on 01/22/16. A nurse's note, transcribed at 2:24 p.m. on 01/22/16, noted notification of the resident's physician regarding the resident's pain. The resident stated the Tylenol was not helping much. The nurse also documented on the pain flow sheet the resident's physician was notified the pain medication was not effective. -- On 01/22/16, the resident received Tylenol 650 mg at 8:00 p.m. for a pain rating of 10, indicating excruciating pain. After repositioning, the resident rated her pain as a 10 at 9:00 p.m. -- On 01/23/16, the resident received Tylenol 650 mg for a pain rating of 10, indicating excruciating pain, at 7:30 a.m. After repositioning, the resident rated her pain as a 10 at 8:30 a.m. -- On 01/23/16, the resident rated her pain at 10, indicating excruciating pain, at 9:00 p.m. The nurse gave the resident Tylenol 650 mg and the resident was repositioned. At 10:00 p.m., her pain remained at a 10. -- At 1:00 a.m. on 01/24/16, the resident rated her pain as 10. Tylenol 650 mg was administered and at 2:00 a.m., the nurse documented the resident's pain was still a 10 and the medication was not effective. -- On 01/25/16, the resident was seen at the facility by her physician at 12:22 p.m. The physician noted the resident's pain in her left hip was, .not controlled on her current regimen of Tylenol 650 mg. po (by mouth) q 6 (every 6 hours) prn (as needed). The physician ordered [MEDICATION NAME] 5 mg. every 4 hours as needed. The resident never received the [MEDICATION NAME] because she left the facility at 3:49 p.m. on 01/25/16, for an appointment with her orthopedic physician. The orthopedic physician admitted the resident to the hospital for a debridement of her wound. The resident never returned to the facility after this discharge. The resident voiced excruciating pain on three (3) of the five (5) days she resided at the facility and received no additional pain medications during her stay. At 11:43 a.m. on 05/11/16, when interviewed regarding the resident's pain management flow sheet, the Director of Nursing (DON) said, I would have expected the physician to be notified if the pain management was not effective. The DON was unable to provide documentation the resident's physician was notified of the resident's pain on any other occasion, other than the note written by the nurse on 01/22/16. The DON was unable to provide documentation of any other interventions other than repositioning and the administration of Tylenol when the resident continued to remain in excruciating pain. The DON confirmed the resident's care plan was not implemented as directed. At 9:15 a.m. on 05/12/16, during an interview, the resident's physician (Physician #97) did not specifically remember the nurse contacting her regarding the resident's pain on 01/22/16. She said if she were contacted she would have done something about the pain. The physician said she would look at her call log and would get back with the information. At 11:41 a.m. on 05/16/16, the DON said he had talked with the resident's physician and the physician said she could not find anything on her call log indicating anyone contacted her regarding Resident #76's pain prior to her visit on 01/25/16. At 2:45 p.m. on 05/16/16, the DON, the Administrator, and Registered Nurse (RN) #102, a facility consultant, were advised the care plan for Resident #76 was not followed and asked if they had any other information to present. At the close of the survey at 4:30 p.m. on 05/18/16, the facility provided no information. b) Resident #48 1. On 04/21/16, the physician wrote an order directing a suction machine at bedside at all times with a [MEDICATION NAME] (an oral suctioning device with a large opening) as the resident was coughing up thick mucus. Review of the resident's current care plan found the following problem: Resident exhibits or is at risk for fluid volume excess as evidence by [MEDICAL CONDITIONS]. The goal associated with this problem was: Resident will not experience any signs/symptoms of fluid overload as evidenced by the absence of [MEDICAL CONDITION] and dyspnea (difficulty breathing) through next review. Approaches included: Resident to have suction machine at bedside per residents request d/t (due to) coughing up thick mucus. Observation of the resident's room on numerous occasions on 05/11/16 found the suction machine was not present. On 05/12/16, continued observations of the resident's room found the suction machine was not at the resident's bedside. The resident's nurse, Licensed Practical Nurse (LPN) #8, when asked about the suction machine at 8:50 a.m. on 05/12/16, said she did not know it was supposed to be in the resident's room. At 11:00 a.m. on 05/12/16, the DON said the resident did not use the suction machine anymore and the order was going to be discontinued. A nursing note on 05/12/16 at 12:44 p.m., found the suctioning machine was discontinued due to nonuse. The DON confirmed the resident's care plan and physician's orders [REDACTED]. At 2:45 p.m. on 05/16/16, the DON, the Administrator, and Registered Nurse (RN) #102, a facility consultant, were advised of these findings and asked if they had any other information to provide. At the close of the survey at 4:30 p.m. on 05/18/16, no further information was provided. 2. Review of the resident's current care plan found the problem: Resident exhibits or is at risk for gastrointestinal symptoms or complications related to constipation. The goal associated with this problem was: Resident will pass a soft formed stool every (3) three days. Approaches included: Monitor and record bowel movements. Provide bowel regimen, utilize pharmacological agents per physician's orders [REDACTED]. Assess for signs and symptoms of constipation i.e. nausea, vomiting, headache, abdominal distention and cramping. Review of the resident's activities of daily living (ADL) record with the DON at 11:00 a.m. on 05/12/16, found no documentation the resident had a bowel movement for 10 (ten) days - from 04/18/16 through 04/27/16. After review of the Medication Administration Record [REDACTED]. There was no evidence provided the facility recognized/investigated the documentation indicating the resident did not have a BM in over 3 days. The DON also confirmed the care plan was not followed for constipation. 3. Review of the resident's current care plan found the following problem: Resident exhibits or is at risk for impaired renal function and is at risk for complications related to [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) receiving [MEDICAL TREATMENT]. The goals associated with this problem were: [MEDICAL TREATMENT] access (the port-a-cath) will remain patent through next review. Resident will not experience any complications related to chronic insufficiency through next review. Approaches included: Maintain smooth catheter clamps at the bedside (and on patient when out of bed) in case of breakage or excessive bleeding from catheter Observation of the resident's room at 4:05 p.m. on 05/11/16 found the catheter clamps stored in a plastic bag tacked to the resident's bulletin board. At 6:00 p.m. on 05/11/16, an observation noted the resident in an area beside the nurses' station without the clamps. During an interview with the resident, he said the clamps were in his room, but he never took them with him when he left the room. At 10:00 a.m. on 05/12/16, Registered Nurse (RN) #51, the nurse in charge of the resident's unit, observed the resident in therapy and verified the resident did not have the catheter clamps with him when out of the room. RN#51 confirmed the care plan directed the resident to have the clamps with him at all times and the clamps were in his room, tacked to his bulletin board. c) Resident #8 A review of Resident #8's medical record at 12:55 p.m. on 05/10/16, found this resident, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. The resident was deemed to have capacity to make medical decisions and scored a 15 out of 15 on her Brief Interview of Mental Status (BIMS) on her admission minimum data set (MDS), indicating she had no cognitive impairments. Further review of the record found a physician order [REDACTED]. Review of Resident #8's care plan found the following focus statement initiated on 04/27/16, Resident exhibits or is at risk for complications related to Obstructive Sleep Apnea, Seasonal allergies [REDACTED].>The goal associated with this focus statement was, Resident will have no sign/symptoms of respiratory distress through next review. Interventions related to this goal included, C-PAP at night. Settings 10 cm H20 (water). This intervention was added to the care plan on 04/28/16. During an interview at 2:20 p.m. on 05/10/16, Resident #8 stated she had not worn her C-PAP since she had been at the facility. When asked why she had not been wearing her C-PAP, she stated she was waiting for them to get authorization to use it. Observations noted Resident #8 had a C-PAP machine in her room complete with a mask. The C-PAP machine was sitting on her nightstand in the corner of her room and the mask was in a bag hanging around the hose and lodged between the wall and the nightstand. When asked if the C- PAP machine helped he, Resident #8 stated, It helps me some and I would wear it if they would put it on me and get it authorized. During an interview with RN #51 at 4:27 p.m. on 05/10/16, she confirmed Resident #8 did have orders for a C-PAP. She indicated the machine was here when the resident arrived at the facility on 04/20/16, but she (the nurse) had to clarify the order for the settings, which she did on 04/28/16. She stated that as far as she knew they were putting it on the resident at night. An additional interview with Resident #8 at 4:58 p.m. on 05/10/16, with RN #51 present, when again asked again if she had been using her C-PAP while at the facility, she again stated that they had not been putting her C-PAP machine on because they were waiting on authorization. Resident #8 confirmed to RN #51 that she would like to start wearing her C-PAP at night if they would put it on her. RN #51 confirmed that nothing was wrong with Resident #8's memory. She confirmed the resident would know if staff put it on her or not. She stated she was not sure why the staff were not putting it on her. d) Resident #37 A review of Resident #37's medical record at 1:00 p.m. on 05/12/16, found this [AGE] year-old female, admitted to the facility in 2012, was recently hospitalized from [DATE] through 08/10/15. Review of Resident #37's [DIAGNOSES REDACTED]. Review of Resident #37's medication administration records (MAR) from 06/01/15 through 05/12/16 found the resident had a physician's orders [REDACTED]. This order had a start date of 08/28/12. Upon Resident #37's readmission to the facility on [DATE], she was started on the following insulin regimen to control her DM: - [MEDICATION NAME] R 5 units SQ (subcutaneously) 3 times a day at 6:00 a.m., 11:00 a.m., and 4:00 p.m. This medication began on 08/11/15. - Accucheck 4 times a day with slicing scale insulin coverage with [MEDICATION NAME] R if: 111-140 = 1 unit, 141-170 = 2 units, 171-200 = 3 units, 201-230 = 4 units, 231-260 = 5 units, 261-290 = 6 units, 291 - 320 = 7 units, 321 - 350 = 8 units, 351 - 380 = 9 units, 381 - 400 = 10 units, and notify physician if less than 60 or greater than 400. Review of Resident #10's care plan found a focus statement initiated on 02/24/14 of, The resident has a [DIAGNOSES REDACTED]. The goal associated with this focus statement was, Resident will be free of all signs and symptoms of hypo/[MEDICAL CONDITION] (low/high blood sugar) such as: sweating, trembling, thirst, fatigue, weakness, blurred vision until next review. Interventions associated with goal included, Access (sic) and record blood glucose levels per order. Monitor for signs/symptoms of hypo/[MEDICAL CONDITION] and report abnormal findings to the physician. Review of Resident #37's Medication Administration Record [REDACTED] - 09/15/15 - BS 78, - 09/16/15 - BS 78, and - 09/17/15 - BS 109 LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R insulin at 6:00 a.m. The only indication in the medical record as to why LPN #5 held the insulin was on 09/15/15. LPN #5 wrote on the back of the MAR indicated [REDACTED]. There was no evidence LPN #5 contacted the physician to obtain an order to hold the insulin, nor did she notify the physician that she held the insulin. Review of Resident #37's 10/2015 MAR found LPN #5 held the scheduled 6:00 a.m. dose of [MEDICATION NAME] R on: - 10/09/15 - BS 95, - 10/10/15 - BS 78, - 10/15/15 - BS 87, and - 10/27/15 - BS 86 There was no evidence LPN #5 contacted the physician to obtain an order to hold the insulin, nor did she notify the physician that she held the insulin. Further review of the MAR found on 10/20/15, LPN #5 failed to implement the physician's orders [REDACTED]. LPN #5 held Resident #37's insulin, but there was no evidence she took any additional actions outlined in the facility's hypoglycemic protocol. [DIAGNOSES REDACTED] protocol physician's orders [REDACTED]. - Hold all diabetic medications including insulin and oral med's. - Administer rapidly absorbed simple carbohydrate such as 4 ounces (oz.) juice, or 5-6 oz regular soda or tube of Glucose Gel per resident routine. - If Meal time, have resident eat meal. - Repeat blood glucose measurement in 10 - 15 minutes; if above 70, or ordered parameter, give diabetic medications. If below 70, repeat juice and blood glucose measurement X 1. - If no improvement, notify physician. Obtain Specific follow- up orders regarding diabetic medications and glucose monitoring. Follow with meal or snack within one hour. Review of Resident #37's 11/2015 MAR found LPN #5 held the resident's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. on: - 11/01/15 - BS 84, - 11/02/15 - BS 90, - 11/11/15 - BS 91, - 11/12/15 - BS 92, - 11/13/15 - BS 106, and - 11/24/15 - BS 94 Review of Resident #37's 12/2015 MAR found LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. on 12/08/15 for a BS of 93. There was no evidence in the medical record indicating why this medication was held or that the physician was notified and/or gave approval to hold the medication. Review of Resident #37's 01/2016 MAR found LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. on: - 01/23/16 - BS 86, and - 01/24/16 - BS 74 There was no evidence in the resident's medical record identifying why this medication was held or that the physician was notified and/or gave approval to hold the medication. Review of Resident #37's 02/2016 MAR found LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. on: - 02/08/16 - BS 84, - 02/11/16 - BS 72, - 02/12/16 - BS 82, - 02/16/16 - BS 78, - 02/18/16 - BS 87, - 02/21/16 - BS 74, - 02/22/16 - BS 94, and - 02/25/16 - BS 98. There was no evidence contained in the medical record which indicated why this medication was held or that the physician was notified and/or gave approval to hold the medication. Review of Resident #37's 03/2016 MAR found LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. on: - 03/19/16 - BS 97, and - 03/20/16 - BS 100. There was no evidence contained in the medical record which indicated why this medication was held or that the physician was notified and/or gave approval to hold the medication. Review of Resident #37's 04/2016 MAR found LPN #21 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. on: - 04/11/16 - BS 92, - 04/13/16 - BS 89, - 04/16/16 - BS 99, and LPN #5 held the resident's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. on: - 04/17/16 - BS 86 Registered Nurse (RN) #53 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. on : - 04/19/16 - BS 102 There was no evidence contained in the medical record which indicated why this medication was held or that the physician was notified and/or gave approval to hold the medication. Again, the facility's [DIAGNOSES REDACTED] Protocol Physician order [REDACTED]. The only time Resident #37's blood sugar was below 70 was on 10/20/15, at which time staff failed to implement the facility's hypoglycemic protocol (as described previously in this citation). On the other 27 occasions when nurses held Resident #37's insulin, her blood sugar was greater than 70. An interview with LPN #5, beginning at 1:40 a.m. and concluding at 1:51 a.m. on 05/10/16, found she had already initialed Resident #37's [MEDICATION NAME] R, which was due at 6:00 a.m. on 05/10/16 to indicate that it had been administered. When asked if she had given the medication and/or drawn up the insulin in a syringe to administer, she stated, No because I have to hold hers a lot of the time because of her blood sugar. She indicated the resident's blood sugar was low a lot of the times and she would hold her insulin. e) Resident #10 1. Diabetes: Insulin Dependent Review of Resident #10's medical record at 9:45 a.m. on 10/16/15 found this resident most recent readmission to the facility was on 04/28/16 after a hospital stay. Prior to this hospitalization , Resident #10 had remained in the facility since 12/30/14 as a long-term care resident. Review of Resident #10's [DIAGNOSES REDACTED]. Both [DIAGNOSES REDACTED]. Review of Resident #10's physician's orders [REDACTED]. -- [MEDICATION NAME] Solution inject as per sliding scale if: 111-140 = 1 unit, 141-170 = 2 units, 171-200 = 3 units, 201-230 = 4 units, 231-260 = 5 units, 261 - 290 = 6 units, 291 - 320 = 7 units, 321 - 350 = 8 units, 351 - 380 = 9 units, 381 - 400 = 10 units, and notify physician if less than 60 or greater than 400 four times a day before meals and at bedtime. This had an order date of 04/28/16. -- Fingerstick blood glucose two (2) times a day notify physician if less than 70 and greater than 300. This had a start date of 04/30/15 and remained in effect until her readmission to the facility on [DATE]. -- [MEDICATION NAME] (an oral diabetes medication) 50 milligrams by mouth one time a day at 10:00 a.m. This order had a start date of 03/31/15 and remained in effect until her readmission on 04/28/16. During this period, Resident #10 had the following changes made to her [MEDICATION NAME] orders: -- On 07/15/15 she was started on [MEDICATION NAME] 18 units inject one time a day at 12:00 p.m. -- On 09/11/15 her [MEDICATION NAME] was increased to 22 units one time day. -- On 11/09/15 her [MEDICATION NAME] was again increased to 26 units one time a day. -- On 03/02/16 her [MEDICATION NAME] was decreased to 20 units one time a day. -- On 03/30/16 her [MEDICATION NAME] was decreased to 16 units one time a day. -- On 04/28/16 her [MEDICATION NAME] was discontinued and she was started sliding insulin coverage when she was readmitted from a hospitalization . Resident #10 also had orders for a HA1c (glycated hemoglobin) a test to measure blood glucose of a period of 3 months) to be drawn every three (3) months in July, October, January, and April. Review of Resident #10's care plan found a focus statement, initiated on 02/24/14, The resident has a [DIAGNOSES REDACTED]. The goal associated with this focus statement was, Resident will be free of all signs and symptoms of hypo/[MEDICAL CONDITION] such as: sweating, trembling, thirst, fatigue, weakness, blurred vision until next review. Interventions associated with this goal statement included, Access and record blood glucose levels per order. Administer Hypoglycemic medications as ordered. Monitor for signs/symptoms of hypo/[MEDICAL CONDITION] and report abnormal findings to the physician. Review of Resident #10's MARs for 08/01/15 through 05/16/16 found the following occasions when physician notification was required because her blood sugars were greater than 300 and the facility failed to notify the physician therefore no treatment was obtained for Resident #10's [MEDICAL CONDITION]: -- 09/04/15 at 4:00 p.m. her blood sugar was 344. -- 09/25/15 at 4:00 p.m. her blood sugar was 425. -- 10/26/15 at 4:00 p.m. her blood sugar was 430. -- 11/02/15 at 4:00 p.m. her blood sugar was 319. -- 12/27/15 at 4:00 p.m. her blood sugar was 384. -- 02/21/16 at 6:00 a.m. her blood sugar was 305. -- 03/03/16 at 4:00 p.m. her blood sugar was 341. -- 03/10/16 at 4:00 p.m. her blood sugar was 364. -- 03/31/16 at 6:00 a.m. her blood sugar was 401. -- 04/19/16 at 6:00 a.m. her blood sugar was 382. Further review of the MAR for 02/2016, found on 02/24/16 Resident #10's blood sugar at 6:00 a.m. was 443. The nurse contacted the on call physician and/or nurse practitioner and obtained a onetime order for 10 units of Humalog and to recheck the blood sugar in one hour. The Humalog was administered and the MAR indicated [REDACTED]. Also on, 02/26/16 at 6:00 a.m. Resident #10's blood sugar was 318. There was no evidence staff notified the physician of her elevated blood sugar at that time. At 4:00 p.m. when her blood sugar was checked again per physician order, it was even higher at 545. It was only after obtaining this blood sugar that the facility contacted the physician and obtained an ordered for a onetime dose of 14 units of Humalog. There was no evidence of additional blood sugars and/or assessments for Resident #10 on this date to ensure her blood sugar had decreased. Review of the 08/2015 MAR found on 08/16/15 at 4:00 p.m. the resident's blood sugar was 573. When contacted, the physician ordered a onetime dose of Humalog 20 units. Again, there was no evidence of any further assessment of the resident's status on that date, including a recheck of her blood sugar following the administration of the 20 units of Humalog Insulin. Further review of the MARs for 08/01/15 through 05/16/16 found on the following occasions the facility failed to follow its [DIAGNOSES REDACTED] protocol when Resident #10 was found to have a low blood sugar of less than 70, the physician's orders [REDACTED].>-- 04/16/16 at 6:00 a.m. her blood sugar was 48. -- 02/29/16 at 6:00 a.m. her blood sugar was 69. -- 01/10/16 at 6:00 a.m. her blood sugar was 67. -- 01/16/16 at 6:00 a.m. her blood sugar was 67. The facility's [DIAGNOSES REDACTED] protocol sheet outlined the following treatment for [REDACTED]. - Hold all diabetic medications including insulin and oral meds. - Administer rapidly absorbed simple carbohydrate such as 4 ounces (oz.) juice, or 5 -6 oz regular soda or tube of Glucose Gel per resident routine. - If Meal time, have resident eat meal. - Repeat blood glucose measurement in 10 - 15 minutes; if above 70, or ordered parameter, give diabetic medications. If below 70, repeat juice and blood glucose measurement X (times) 1. If no improvement, notify physician. - Obtain Specific follow- up orders regarding diabetic medications and glucose monitoring. Follow with meal or snack within one hour. An interview with the Nurse Practitioner (NP) #96 at 12:48 p.m. on 05/16/16, confirmed that Resident #10 not a well-controlled diabetic. She indicated that she has had to make multiple changes to her drug regimen. She stated that whenever they increased the resident's insulin, she would have [DIAGNOSES REDACTED]. The NP said it was important to treat the resident's [DIAGNOSES REDACTED]. She stated that they had a protocol to follow to treat her [DIAGNOSES REDACTED] and they expected her to have some [MEDICAL CONDITION] that they would treat as it happened because they were trying to avoid the [DIAGNOSES REDACTED] incidents with her. She indicated the resident's normals were for her to be up and down with her blood sugars. At 2:45 p.m. on 05/16/16, these findings were discussed with the DON, Administrator, and Registered Nurse (RN) #102, facility consultant, and any additional information was requested. At the time of exit at 4:30 p.m. on 05/18/16 no further information was provided. 2. Hypertension Resident #10 (Anti-Hypertensive Medications) A review of Resident #10's medical record at 9:45 a.m. on 05/16/16 found, Resident #10 was a long term-care resident at the facility who was hospitalized from [DATE] to 04/28/16. She was readmitted to the facility on [DATE]. Review of Resident #10's 04/28/16 admission physician orders, signed by the physician on 04/29/16, found the following orders to treat her hypertension: -- Carvedilol 3.125 milligrams (mg) two (2) tablets every 12 hours for a [DIAGNOSES REDACTED]. -- [MEDICATION NAME] 10 mg one time daily for a [DIAGNOSES REDACTED]. -- [MEDICATION NAME] 5 mg one time daily for a [DIAGNOSES REDACTED]. A review of Resident #10's care plan found the following focus statement, Resident exhibits or is at risk for cardiovascular symptoms or complications related [MEDICAL CONDITION](hypertension), HLD ([MEDICAL CONDITION]), and h/o (history of) [MEDICAL CONDITIONS]. The goal associated with this focus statement was, Resident will not develop any cardiovascular related complications through the next review. The interventions related to this goal included, Administer med's (medications) as ordered and assess for effectiveness and side effects report abnormalities to physician. Assess and monitor vital signs as ordered and report abnormalities to physicians. Review of Resident #10's Medication Administration Record [REDACTED]. Additional review of the MAR found that Resident #10 had received her [MEDICATION NAME] and [MEDICATION NAME] daily at 10:00 a.m. with no evidence staff obtained her blood pressure prior to the administering these medications. Both medications had a physician ordered parameter directing the medication held if her systolic blood pressure was below certain numbers. This required the nurse to obtain the blood pressure prior to administration to evaluate for the need of the medication. There were no blood pressures documented in the medical record obtained within an hour prior to the administration of either medication with the exception of 05/03/16 when the resident's documented blood pressure was 134/74 at 9:29 a.m. An interview with the DON at 4:53 p.m. on 05/16/16, confirmed that Resident #10 was not receiving her Carvedilol as ordered by the physician. He indicated she was only getting it one (1) time a day the entire month of (MONTH) and she should have received it twice daily. The DON also reviewed the medical record and confirmed that on every day in (MONTH) (YEAR), except for 05/03/16, there was no indication nursing had obtained Resident #10's blood pressure prior to the administration of her [MEDICATION NAME] and [MEDICATION NAME]. <br",2019-05-01
4944,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,311,D,1,0,1MMH11,"> Based on record review, staff interview, and policy review, the facility failed to provide appropriate treatment and services to maintain or improve a resident's abilities to toilet after a decline in bowel continence. Resident #48 experienced a significant decline in bowel continence within the first month of admission. The facility failed to assess the causes of the decline and provide treatment and services to improve/maintain the resident's continence. This was true for one (1) of nine (9) residents' records reviewed during the complaint survey ending on 05/18/16. Resident identifier: #48. Facility census: 72. Findings include: a) Resident #48 Review of the resident's admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 04/22/16, found the resident required the extensive assistance of one person for toileting use. The assessment also identified the resident as being only occasionally incontinent of bowel. The next MDS, a 14-day MDS, with an ARD of 04/29/16, assessed the resident as requiring extensive assistance of two (2) staff members for toileting and as always incontinent of bowel. This was a significant decline in the resident's bowel continence from occasionally incontinent to always incontinent of bowel. At 9:47 a.m. on 05/12/16, when asked about the resident's decline in bowel continence, MDS Registered Nurse (RN) #3 said she did not know anything about the decline. She said RN #51 completed that section so she should be asked about the decline. In an interview at 10:00 a.m. on 05/12/16, RN #51 said she was also unaware of why the resident had declined in bowel continence. Review of the resident's current care plan, revised on 04/25/16, found the resident was only occasionally incontinent of bowel. The goal associated with this problem was for the resident not to be more than occasionally incontinent of bowel through the next review. Relevant interventions included: Encourage resident to use toilet upon awakening, after meals, nightly and PRN (as needed) Physical therapy and Occupational therapy as needed. At 11:00 a.m. on 05/12/16, the director of nursing (DON) reviewed the resident's three-day continence management diary. The diary, initiated on 04/15/16, directed the following codes to be used when completing the diary: CB = continent bowel (toileted) IB = Incontinent bowel CU = Continent urine (toileted) IU = Incontinent urine D = (not toileted) The diary was not dated for each day completed as directed. The resident was coded as a C or a D. The coding instructions did not include a C, therefore, it was not clear what the coding pertained to. It was also unclear if the diary was coded for the urine or the bowel because it was not specified. The DON confirmed the diary was not completed according to the directions. At 3:54 p.m. on 05/16/16, the DON provided a copy of the facility's policy, entitled Continence Management. The policy directed: A urinary incontinence assessment and/or bowel incontinence assessment and the Three-Day Continence Management Diary will be completed if the patient is incontinent upon admission or re-evaluation and with a change in condition or change in continence status. Continence status will be reviewed quarterly and with significant change as part of the nursing assessment 1. Identify patient's continence status and need for management by reviewing the nursing assessment. 2. If patient is incontinent,: Electronic Medical Record System-complete urinary incontinence assessment and/or bowel retraining assessment. Non-electronic Medical Record Systems-Complete a urinary and/or bowel incontinence evaluation. 3. Address transient causes for incontinence. 4. Initiate Three-Day Continence Management Diary if continence is not resolved. 5. Develop plan of care based on information from assessments and Diaries. 6. Implement revisions to the plan of care as needed The DON was unable to provide any evidence the facility addressed the resident's decline in bowel continence. There were no further assessments provided. Staff to determine possible reasons for the decline did not interview the resident, who was alert and oriented. The resident's care plan did not address the decline. The diary was not completed according to the directions. The resident was not offered a toileting program or any special equipment such as a bedside commode, or other measure to address the incontinence. On 2:45 p.m. on 5/16/16, these issues were discussed with the DON, the administrator, and Corporate RN #102. The three (3) employees did not provide any further information as of the close of the survey at 4:30 p.m. on 05/18/16.",2019-05-01
4945,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,322,D,1,0,1MMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations and staff interviews, the facility did not provide care and services to Resident #68 to ensure the resident did not experience complications resulting from allowing tube-feeding formula to hang too long. Staff failed to label a bag of [MEDICATION NAME] to identify when the bag was hung and by when it should be discarded. This affected one (1) of thirteen (13) sample residents. Resident identifier: #68. Facility census: 72. Findings include: a) Resident #68 Observation of Resident #68's enteral feeding on 05/12/16 at 10:15 a.m., found a bottle of [MEDICATION NAME] 1.5 calories per milliliter (cal/ml) tube feeding solution hanging with no name, or date and time the feeding was hung. The feeding was not infusing at that time. Medical record review on 05/12/16 at 10:30 a.m., found a physician's orders [REDACTED]. To be infused starting at 11:00 p.m. nightly and stopped at 7:00 a.m. by the gastrostomy tube. Interview with Licensed Practical Nurse (LPN) #8 on 05/12/16 at 10:45 a.m., confirmed the bottle of [MEDICATION NAME] feeding solution had no name, or date and time to identify when the solution was opened and hung. She immediately removed the bottle and tube from the feeding pump. The Director of Nursing (DON) was informed, but provided no other information. Once opened, unless refrigerated, [MEDICATION NAME] must be discarded after 24 to 48 hours, depending on the type of tubing used to deliver the feeding. Without a date and time to identify when the feeding was opened, the facility could not ensure it was used safely.",2019-05-01
4946,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,328,G,1,0,1MMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to follow the recommended physician's order/recommended care of the [MEDICAL CONDITION] from the transferring facility to ensure Resident #73 received the necessary [MEDICAL CONDITION] care and respiratory services related to her [MEDICAL CONDITION] (TBI). The lack of necessary [MEDICAL CONDITION] care and respiratory services caused actual harm requiring an unplanned hospitalization . This was true for one (1) of one (1) resident reviewed for [MEDICAL CONDITION]. Resident identifier: #73. Facility census: 72. Findings include: a) Resident #73 Review of Resident #73's medical records on [DATE] at 1:00 p.m., found the resident, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. The resident's Brief Interview for Mental Status (BIMS), completed on the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE], score was 15, indicating the resident was cognitively intact. Review of the transferring facility's discharge orders/recommendations found the following [MEDICAL CONDITION] and respiratory orders/recommendations: -- Keep patient on room air (RA) during the day as tolerated to keep oxygen (O2) at 90 percent (%) or above and humidified 35% fraction of inspired oxygen (FIO2) via [MEDICAL CONDITION] (trach) collar overnight. -- Continue to obtain oxygen saturation (O2 sat) to maintain oxygen level at 90% or above. -- Suction when necessary (PRN). --[MEDICAL CONDITION] twice a day and PRN -- [MEDICAL CONDITION] for signs/symptoms of infection every shift -- [MEDICAL CONDITION] twice daily and PRN -- [MEDICAL CONDITION] using sterile technique -- [MEDICAL CONDITION] weekly on day shift Resident #73's admission physician orders dated [DATE], had orders for oxygen use and/or O2 saturation monitoring. On [DATE], Resident #73 was examined and an admission history and physical (H&P) was completed by the attending physician and new orders given to consult with a respiratory therapist (RT) for evaluation and treatment of [REDACTED]. The RT consult, dated [DATE] at 1:29 p.m., included new orders for FIO2 at 35% [MEDICAL CONDITION] at all times. Review of the Treatment Administration Record (TAR) for (MONTH) (YEAR), found no evidence [MEDICAL CONDITION] including the inner cannula was performed on [DATE], [DATE], [DATE], or [DATE] on the ,[DATE] shift. The facility's [MEDICAL CONDITION] care policy/procedure included: -- Perform [MEDICAL CONDITION] (trach) care at least twice a day and PRN as ordered. -- Evaluate patients heart rate, respiratory rate, breath sounds, and cough effort. Evaluate sputum amount, color, and consistency prior [MEDICAL CONDITION] and after the procedure. --Document the date and time of procedure, observation at stoma site, heart rate, respiratory rate, breath sounds, and cough effort pre and post procedure and patient's response to procedure. There was no evidence in the resident ' s medical record to indicate staff implemented the facility ' s policy and procedure [MEDICAL CONDITION]. Additional review of Resident #73's nursing progress notes found an entry by Registered Nurse (RN) #53 on [DATE] at 4:25 p.m. The nurse documented (typed as written), Heard loud sounds coming from resident's room as if objects were being thrown, entered room to see objects flying off of the bed onto the floor, resident had the head of her bed up around 30 degrees and was leaned back on bed. Face and hands blue, had jerking motions of her head to the left side and was struggling to breathe/ her mouth was open with clear/foamy sputum coming out. checked for carotid pulse/positive/jugular distention to the right side. Yelled out for help from staff who came to assist me. Another progress note by Licensed Practical Nurse (LPN) #11, on [DATE] at 4:44 p.m., noted (typed as written), Resident became unresponsive at about 4:20 p.m., crash cart accessed, O2 sat, 911 called, family notified (husband) resident became responsive at about 4:40 p.m., sent to (Name of Hospital) for further assessment. Another progress note entered by LPN #11 on [DATE] at 4:35 p.m., stated (Resident #73 name) transferred to hospital-unplanned for evaluation and treatment . Resident became unresponsive and shallow breathing.[MEDICAL CONDITION] repeatedly. Vitals ,[DATE]- blood pressure, heart rate (HR) 110 and O2 sats 95%. Became responsive. Emergency Medical Squad (EMS) arrived at 4:30 p.m. and transferred to the hospital. Review of the EMS report found on [DATE] at 4:51 p.m., the EMS arrived on the scene due to a report of an unconscious, apneic (not breathing) and pulseless female and resident was assessed and transported to local hospital and arriving at the hospital at 5:03 p.m. On [DATE] at 6:00 p.m., review of Resident #73's emergency room (ER) reports found, .She was unable to breath and blacked out and apparently they may or may not have done cardiopulmonary resuscitation (CPR) but she did not have any chest tenderness. She was sent here after they bagged her for a while or did something else to get the air back in her, it is unclear in their report verbal or otherwise and here, it was noted she was getting increasingly dyspneic (difficulty breathing) and pulling a lot of negative inspiratory pressure. We took out the cannulated portion of [MEDICAL CONDITION] part that is removable and found a large obstructing mucus plug and cleaned that out, put it back in and she did a lot better The resident ' s respiratory distress and resulting emergency transfer to the hospital constituted actual harm. During an interview with the Director of Nursing (DON) on [DATE] at 2:15 p.m., when asked if the resident had received [MEDICAL CONDITION] and oxygen as recommended by the transferring facility, he said, It doesn't appear she did. He was unable to provide any further details concerning [MEDICAL CONDITION] and respiratory services provided Resident #73's during her stay at the facility ([DATE] through [DATE]).",2019-05-01
4947,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,428,E,1,0,1MMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility's pharmacist failed to review each resident ' s drug regimen and report irregularities to the Director of Nursing and/or Physician for two (2) of twelve (12) sampled residents. Nurses held Resident #37's scheduled insulin on a consistent basis month to month for multiple months. The pharmacist failed to identify the nursing staff was holding Resident #37's insulin without justification or an order from the physician. Resident #68 was receiving two (2) antihypertensive medications for which had physician-established parameters to hold if her pulse and/or blood pressure fell below a certain number. The facility failed for multiple months to obtain Resident #68 ' s blood pressure or pulse prior to administering the medications. The pharmacist failed to identify this irregularity and report it to the Director of Nursing and/or physician. Resident Identifiers: #37 and #68. Facility Census: 72. Findings Include: a) Resident #37 A review of Resident #37 medical record at 1:00 p.m. on 05/12/16 found this [AGE] year-old female, admitted to the facility in 2012, was in the hospital from 08/07/15 through 08/10/15. Upon Resident #37's readmission to the facility on [DATE], the physician ordered following insulin regimen to control her Type 2 diabetes mellitus: - Humulin R 5 units SQ (subcutaneously) three (3) times a day at 6:00 a.m., 11:00 a.m., and 4:00 p.m. This medication began on 08/11/15. (Humulin R is a fast-acting insulin with a short duration of action.) - Accucheck (test for glucose levels) four (4) times a day with scale insulin coverage with Humulin R if: 111-140 = 1 unit, 141-170 = 2 units, 171-200 = 3 units, 201-230 = 4 units, 231-260 = 5 units, 261 - 290 = 6 units, 291 - 320 = 7 units, 321 - 350 = 8 units, 351 - 380 = 9 units, and 381 - 400 = 10 units notify physician if less than 60 or greater than 400. Review of Resident #37's Medication Administration Record [REDACTED] - on 09/15/15 - BS 78, - on 09/16/15 - BS 78, and - on 09/17/15 - BS 109 LPN #5 held Resident #37's scheduled dose of Humulin R insulin at 6:00 a.m. The only indication in the medical record as to why LPN #5 held the insulin was noted on 09/15/15 by LPN #5 who wrote on the back of the MAR indicated [REDACTED]. There was no evidence that LPN #5 contacted the physician to obtain an order to hold the insulin, nor did she notify the physician that she held the insulin. Review of Resident #37's 10/2015 MAR found LPN #5 held the scheduled 6:00 a.m. dose of Humulin R on: - 10/09/15 - BS 95, - 10/10/15 - BS 78, - 10/15/15 - BS 87, and - 10/27/15 - BS 86 Further review of the MAR found on 10/20/15, LPN #5 failed to implement the facility's [DIAGNOSES REDACTED] Protocol physician's orders [REDACTED]. The facility's [DIAGNOSES REDACTED] Protocol physician's orders [REDACTED]. Administer rapidly absorbed simple carbohydrate such as 4 ounces (oz.) juice, or 5-6 oz regular soda or tube of Glucose Gel per resident routine. If Meal time, have resident eat meal. Repeat blood glucose measurement in 10 - 15 minutes; if above 70, or ordered parameter, give diabetic medications. If below 70, repeat juice and blood glucose measurement X 1. If no improvement, notify physician. Obtain Specific follow- up orders regarding diabetic medications and glucose monitoring. Follow with meal or snack within one hour. LPN #5 held Resident #37's insulin, but there was no evidence she took any additional actions outlined in the facility's hypoglycemic protocol. Review of Resident #37's 11/2015 MAR found LPN #5 held the resident's scheduled dose of Humulin R at 6:00 a.m. on: - 11/01/15 - BS 84, - 11/02/15 - BS 90, - 11/11/15 - BS 91, - 11/12/15 - BS 92, - 11/13/15 - BS 106, and - 11/24/15 - BS 94 Review of Resident #37's 12/2015 MAR found LPN #5 held Resident #37's scheduled dose of Humulin R at 6:00 a.m. on 12/08/15 for a BS of 93. There was no evidence in the medical record which indicated why this medication was held or that the physician was notified and/or gave approval to hold the medication. Review of Resident #37's 01/2016 MAR found LPN #5 held Resident #37's scheduled dose of Humulin R at 6:00 a.m. on: - 01/23/16 - BS 86, and - 01/24/16 - BS 74 There was no evidence in the resident's medical record identifying why this medication was held or that the physician was notified and/or gave approval to hold the medication. Review of Resident #37's 02/2016 MAR found LPN #5 held Resident #37's scheduled dose of Humulin R at 6:00 a.m. on: - 02/08/16 - BS 84, - 02/11/16 - BS 72, - 02/12/16 - BS 82, - 02/16/16 - BS 78, - 02/18/16 - BS 87, - 02/21/16 - BS 74, - 02/22/16 - BS 94, and - 02/25/16 - BS 98. There was no evidence contained in the medical record which indicated why this medication was held or that the physician was notified and/or gave approval to hold the medication. Review of Resident #37's 03/2016 MAR found LPN #5 held Resident #37's scheduled dose of Humulin R at 6:00 a.m. on: - 03/19/16 - BS 97, and - 03/20/16 - BS 100. There was no evidence contained in the medical record which indicated why this medication was held or that the physician was notified and/or gave approval to hold the medication. Review of Resident #37's 04/2016 MAR found LPN #21 held Resident #37's scheduled dose of Humulin R at 6:00 a.m. on: - 04/11/16 - BS 92, - 04/13/16 - BS 89, - 04/16/16 - BS 99, and LPN #5 held the resident's scheduled dose of Humulin R at 6:00 a.m. on: - 04/17/16 - BS 86 Registered Nurse (RN) #53 held Resident #37's scheduled dose of Humulin R at 6:00 a.m. on : - 04/19/16 - BS 102 There was no evidence contained in the medical record which indicated why this medication was held or that the physician was notified and/or gave approval to hold the medication. Again, the facility's [DIAGNOSES REDACTED] Protocol Physician order [REDACTED]. The only time Resident #37's blood sugar was below 70 was on 10/20/15, at which time the facility's hypoglycemic protocol (described previously in this citation) was not implemented. On the other 27 occasions when Resident #37's insulin was held her blood sugar was greater 70. An interview with LPN #5, beginning at 1:40 a.m. and concluding at 1:51 a.m. on 05/10/16, found she had already initialed Resident #37's Humulin R, which was due at 6:00 a.m. on 05/10/16, to indicate that it had been administered. When asked if she had given the medication and/or drawn up the insulin in a syringe to administer, she stated, No because I have to hold hers a lot of the time because of her blood sugar. She indicated the resident's blood sugar was low a lot of the times and she would hold her insulin. Further review of Resident #37's medical record found the pharmacist had reviewed the resident's drug regimen on 09/18/15, 10/08/15, 11/12/15, 12/09/15, 01/14/16, 02/08/16, 03/04/16, 04/05/16, and 05/06/16. The pharmacist made recommendations on 03/04/16, 10/08/15, and 09/18/15, but those recommendations were not related to nursing continually holding Resident #37's insulin without cause or notification of the physician. The pharmacist made no recommendations on the other drug regimen review dates. At 2:45 p.m. on 05/16/16, these findings were discussed the DON, Administrator, and a Registered Nurse (RN) #102, a facility consultant, and any additional information was requested. At the time of exit at 4:30 p.m. on 05/18/16, the staff provided no further information. d) Resident #68 On 05/16/16 at 10:30 a.m., a review of Resident #68's medical record revealed an admission date of [DATE]. Admission physician's orders [REDACTED]. Lopressor 75 milligrams (mg) by feeding tube every twelve (12) hours) for the treatment of [REDACTED]. Hold if heart rate (HR) less than 60. (Some medications for high blood pressure also cause the heart rate to slow.) A review of the Medication Administration Record [REDACTED]. The resident's pulse was not obtained prior to the administration of the medication until 12/01/15. Additionally, Resident #68 received Lopressor 75 mg by feeding tube at 10:00 a.m. and 10:00 p.m. daily, beginning on 08/22/15 through 11/30/15. The resident's blood pressures and/or pulses were not obtained prior to the administration of the medication until 12/01/15. Review of the consultant pharmacy Monthly Medication Reviews (MMR) from (MONTH) through (MONTH) (YEAR), found no recommendations concerning the physician ordered parameters for Digoxin and Lopressor not being followed. An interview with DON at 2:33 p.m. on 05/16/16, confirmed Resident #68's blood pressure and pulse were not obtained prior to the administration of Lopressor and Digoxin from 08/21/15 through 11/30/15 in accordance with the physician's orders [REDACTED].",2019-05-01
4948,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,431,E,1,0,1MMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, resident interview, policy review, and staff interview, the facility failed to ensure all controlled substances were stored in a separately locked, permanently affixed compartment on the medication cart. The Licensed Practical Nurse (LPN) working on the 100 hall on the night of [DATE] into the morning of [DATE] pre-poured controlled substances for Resident #44, #40, #65, and #19's several hours before the medications were due to be administered. Therefore, the controlled substances were not in a permanently affixed and separately lock compartment on the medication cart. Additionally, the facility staff failed to label an intravenous (IV) antibiotic and enteral feeding in accordance with currently accepted professional standards. An empty IV medication bag on an IV pole for Resident #8 did not have the nurse ' s initials, or the date and time of administration. The facility also failed to ensure the crash cart (a cart with supplies needed during an emergency) did not contain expired items. These findings had the potential to affect more than an isolated number of residents. Resident Identifiers: #8, #44, #40, #65, and #19. Facility Census: 72. Findings Include: a) Storage of Narcotics A review of the Medication Administration Records (MARs) on the 100 hall beginning at 1:26 a.m. on [DATE] found the following areas of concern: -- Resident #19's dose of Tramadol, scheduled at 6:00 a.m. was already initialed as given at the time of this review. -- Resident #44's 6:00 a.m. dose of Norco ,[DATE] was initialed as given at the time of this review. -- Resident #40's 6:00 a.m. dose of morphine was already initialed as given at the time of this review. -- Resident #65's 4:00 a.m. dose of Percocet was already initialed as given at the time of this review. An interview with Licensed Practical Nurse (LPN) #5 beginning at 1:40 a.m. and concluding at 1:51 a.m. on [DATE], revealed she had initialed the MARs early so she would not forget to do it later. When asked if she had signed out the narcotics on the controlled substance log, she indicated they were. At that time, review of the controlled substance log compared to the actual number of medications on hand, revealed the LPN had already removed the medications from the medication cards, and placed them in medication cups labeled with the resident ' s room number, and placed the cups in the top drawer of the medication cart. The nurse stated that she got the medications ready in advance because she thought she was going to be busy and wanted to get all of her medications ready for the remainder of the night. When asked if this was an appropriate nursing practice, she stated, No you should pull the medication at the time they are due. She further stated, You should also not initial the MAR or controlled substance sheet until the time of administration. At 1:54 a.m. on [DATE], when informed of the LPN signing out all medication and placing them in medication cups in the top drawer or the medication cart, the Director of Nursing agreed this was not an acceptable nursing practice and controlled substances should not be removed from the narcotic drawer until time of administration. b) Resident #8 A review of Resident #8's medical record at 12:55 p.m. on [DATE], found the resident was receiving Rocephin (an antibiotic) two (2) grams IV daily at 10:00 a.m. with a stop date of [DATE]. An observation of Resident #8 at 2:15 p.m. on [DATE], found an empty medication bag hanging on her IV pole. The resident indicated that it was her IV antibiotic. She stated, I have already had it today. Observation of the bag noted the bag labeled as Rocephin and the printed label contained the resident ' s name. However, the medication bag label did not include the initials of the person who administered the medication, nor the date and time the medication was administered. An interview with LPN #11 at 2:30 p.m. on [DATE], confirmed he was the nurse who had administered the medication. He stated that he should have put his initials on the medication as well as the date and time of administration. When asked when this medication was administered he stated, I gave it to her this morning at 10:00 a.m. He stated he had forgotten to put his initials and the date and time. He said he had remembered he needed to do that earlier, but had not gotten back to do it yet. At 2:30 p.m. on [DATE], review of the facility's policy Storage and Expiration of Drug, Biological's, Syringes and Needles found it included, The center will ensure that infusion therapy labels include the drug name, volume, infusion rate, name and quantity of each additive, date of preparations, initials of compounder, date and time of administration, initials of person administering the medication, ancillary labeling and expiration date. c) Observation of the Crash Cart Observation of the crash cart at 2:10 a.m. on [DATE], with the director of nursing (DON) found the following expired supplies on the cart: - Sterile water, 3.7 ounces, expiration date was ,[DATE] (October (YEAR)). - Sterile water, 8.5 ounces, (two (2) bottles) - One (1) expired ,[DATE] (October (YEAR)) and the second expired ,[DATE] (March (YEAR)). - Instant hand sanitizer, two (2) bottles, both expired ,[DATE] (November (YEAR)). - Lubricating Jelly, three (3) packages - two (2) packages expired ,[DATE] (March (YEAR)) and one (1) package expired ,[DATE] ([DATE]). The DON confirmed the items were expired and he said he would discard the items. Review of the facility's policy for Storage and Expiration Dating of Drugs, Biological's, Syringes, and Needles found the following: .3. Drugs and biological's that have an expired date on the label or are after manufacturer/supplier guidelines/recommendations, or if contaminated or deteriorated, are stored separately, away from use, until destroyed or returned to the provider",2019-05-01
4949,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,441,F,1,0,1MMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. The facility failed to ensure all visitors/family members or anyone having skin to skin contact with residents during a known outbreak of scabies in (MONTH) (YEAR) were notified of the outbreak, failed to organize data according to time, place, and person, failed to formulate a hypothesis of the outbreak. Additionally, the facility failed to identify the origin of Resident #31's infection (Extended Spectrum Beta-Lactamase (ESBL) and for Resident #75 failed to identify the origin of her infections of ESBL, [MEDICATION NAME]-Resistant [MEDICATION NAME] (VRE), and Methicillin-resistant Staphylococcus aureus (MRSA). Resident identifiers: #31 and #75. Facility Census: 72. Findings include: a) (MONTH) (YEAR) - Scabies Outbreak 1. On 05/11/16 at 11:15 a.m., a review of the monthly surveillance report for (MONTH) (YEAR), found no evidence the facility had informed the families/visitors or any persons entering the facility of a known outbreak of scabies. Review of the facility ' s infection control procedure found in Section 7: Implement control measures based on signs, symptoms, diagnosis, mode of transmission, and location in the center. Measures may include: Visitor precautions/limitations Additionally, review of the facility ' s policy for Outbreak Investigation/Management found step 10: Complete the Outbreak Investigation Summary and submit a copy to the director of nursing (DON), administrator, medical director, and the health department. This report was to summarize data/information collected, include case definition, a hypothesis, and final evaluation of the outbreak. Interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 05/11/16 at 3:10 p.m., revealed the facility had only notified the family/responsible party of the outbreak and treatment of [REDACTED]. They both confirmed all visitors were not informed of an outbreak. Additionally, they both confirmed the Outbreak Investigation Summary was not completed as directed by the facility's policy. 2. Health Department Interview and Report concerning Scabies Outbreak in (MONTH) (YEAR). A telephone interview on 05/17/16 at 11:30 a.m., with the local health department revealed the facility had a reported scabies outbreak, which was first observed on 11/17/15 and reported to the local health department on 11/18/15 at 9:15 a.m. The Health Department report stated 12 of 72 residents and 10 of 84 employees had signs/symptoms of a rash on the waist, abdomen, back and few had a generalized rash. The medical director initiated treatment of [REDACTED]. The three (3) skin scrapings tested were negative for scabies. Also, the felt tip test (a washable marker is used to color the skin, then removed and observed for tracts and/or mites) was performed by the medical director with negative results. On 11/23/15, a conference call with the facility and local health department revealed the facility had decided to treat all residents and employees on 11/18/15 and planned to do a second treatment on 11/25/15 with special cleaning of the entire facility. During the call it was discussed about the residents who did see a dermatologist; the dermatologist felt it could be contact dermatitis or possibly bug bites. The facility did check for bed bugs and the results were negative. The facility did add another rinse cycle to better remove detergent from the laundry. On 12/07/15 due to no new onset, the last reported onset was 11/19/15, the scabies outbreak surveillance was closed due to last reported onset was over two (2) weeks. The closing of the outbreak was emailed to the facility on [DATE]. The health department stated, The facility followed all of our suggestions and direction during the scabies outbreak in (MONTH) (YEAR). c) Resident #31 Record review at 3:00 p.m. on 05/10/16, found the resident was initially admitted to the facility on [DATE]. The most recent hospital discharge summary, dated 05/04/16, noted the resident had ESBL (Extended Spectrum Beta-Lactamase - an enzyme produced by some bacteria) and required contact precautions. Review of the infection control monthly line listing found Resident #31 was not on the (MONTH) (YEAR) infection list. Further record review found the resident's initial hospital discharge summary, dated 12/24/15, noted the resident was discharged to the facility with Clostridium difficile (C-diff) and ESBL. Review of the infection control monthly line listing for (MONTH) (YEAR), found the resident was on contact precautions for[DIAGNOSES REDACTED]., not ESBL. At 4:29 p.m. on 05/10/16, Registered Nurse (RN) #54, the nurse educator in charge of the facility's infection control program, confirmed Resident #31 was currently not on contact precautions. RN #54 said, Isolation precautions at the hospital are different from here, if the infection is contained then isolation is not required. When asked where the ESBL was located, RN #54 said she did not know, but thought the infection was in the biliary drains (a drainage catheter inserted into the bile duct when the duct is obstructed). She was informed Resident #31 did not have the biliary drains when admitted on [DATE], the drains were not placed until (MONTH) (YEAR). RN #54 then said the ESBL was in the resident's urine and she was continent. She was informed the resident was frequently incontinent of urine as indicated on her most recent minimum data set (MDS) with an assessment reference date (ARD) of 04/18/16. RN#54 then said she would have to call the hospital to get the laboratory reports to determine where the infection was located. At 4:50 p.m. on 05/10/16, RN #54 returned with a laboratory report from 12/11/15 which noted, Positive Blood Culture, Escherichia Coli ESBL, Attention ESBL!!! Follow Contact Precautions. At 10:56 a.m. on 05/11/16, the director of nursing (DON) said infections that were contained only required standard precautions. When asked how the facility could determine the infection was contained if the facility did not know where the infection was located, the DON was unable to answer the question, At 2:57 p.m. on 05/17/16, RN #54 confirmed she did not know the source/origin of the ESBL prior to surveyor intervention on 05/10/16. d) Resident #75 Review of Resident #75's medical record at 9:15 a.m. on 05/11/16, found the resident had an acute hospitalization on [DATE], and returned to the facility on [DATE]. Review of the hospital discharge summary found the resident's final [DIAGNOSES REDACTED]. -- Acute chronic respiratory failure secondary to severe Chronic Obstructive Pulmonary Disease (COPD) and Methicillin resistant staph aureus (MRSA) pneumonia. -- Extended Spectrum beta-lactamase (ESBL) urinary tract infection colonization. Review of the facility's Multi Drug Resistant Organism (MRDO) Master List (a list maintained by the facility's infection control nurse to track which residents had a history of [REDACTED].#75 had a history of [REDACTED]. The MRDO master list indicated Resident #75's admitted to the facility was 09/25/15. At 4:00 p.m. on 05/16/16, the Infection Control Nurse was asked where the resident ' s MRSA, ESBL and VRE infections were located and she stated I have that information, I will have to go look for it and bring it back. On 05/17/16 at 2:45 p.m., the Infection Control Nurse provided four (4) lab results from a local hospital, which showed the resident had: - VRE (Lab dated 01/19/10) in her urine - MRSA in the her sputum (lab dated 07/31/10) - MRSA in her blood (lab dated 01/02/14), and - ESBL (Lab dated 01/14/16). At the top of each lab result was the date of 05/16/16 and a time of 4:50 p.m. which indicated the local hospital had faxed this information to the facility on [DATE] at 4:50 p.m. The Infection Control Nurse was unable to find in the resident ' s medical record at the facility where the location of her (resident ' s) infections were, even though the MRSA in the sputum and ESBL in the urine was contained on the hospital discharge summary the facility received on 09/25/15. When the surveyor requested the information, the nurse had to call and get the lab results from the local hospital in order to accurately state where the resident ' s infections were previously located. The nurse did not have knowledge of where these infections were located prior to surveyor intervention.",2019-05-01
4950,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,502,D,1,0,1MMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility failed to obtain physician ordered laboratory services for two (2) of twelve (12) sampled residents. The facility failed to obtain a Complete Blood Count (CBC) for Resident #75, and failed to obtain Resident #10's Hemoglobin A1c (HGA1c) in (MONTH) (YEAR). Resident Identifiers: #10 and #75. Facility Census: 72. Findings Include: a) Resident #75 A review of Resident #75's medical record at 9:10 a.m. on 05/11/16, found a progress note from her pulmonologist dated 10/14/15. This progress note indicated the pulmonologist wanted to obtain a CBC to see whether an infection was causing the resident ' s change in mental status. The pulmonologist sent back to the facility a printed physician's orders [REDACTED]. An interview with the Director of Nursing (DON) at 10:18 a.m. on 05/12/16, confirmed the facility failed to obtain the CBC as ordered by the pulmonologist and approved by her attending physician. The DON indicated he contacted the pulmonologist ' s office to see if they had obtained it and they had not. b) Resident #10 A review of Resident #10's medical record at 9:45 a.m. on 05/16/16 found a physician's order [REDACTED]. Further review of the medical record found Resident #10 should have had a HGBA1c obtained on 10/30/15, but the facility failed to obtain this lab as ordered. Her HGBA1c obtained on 07/15/15 was elevated at 9.9, and when rechecked on 08/03/15, remained elevated at 9.0. The facility failed to obtain the next scheduled check of her HGA1c on 10/30/15. At 12:32 p.m. on 05/16/16, the DON was asked to provide the results of the HGBA1c that was ordered for 10/30/15. As of the time exit on 05/18/16 at 4:30 p.m., he had provided no results. He confirmed at that time it appeared they had not obtained this lab as ordered.",2019-05-01
4951,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,507,D,1,0,1MMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure laboratory (lab) test results were filed in the clinical record for one (1) of twelve (12) sampled residents. Resident #75's [MEDICATION NAME] time/international normalized ratio (PT/INR) test results were not in her clinical record. Resident Identifier: #75. Facility Census: 72. Findings Include: a) Resident #75 Review of Resident #75's medical record at 9:10 a.m. on 05/11/16, found a physician's orders [REDACTED]. Stat (immediate) INR today. Further review of the record found the results of a PT/INR obtained on the morning of 03/25/16. The results of this INR prompted the orders for a stat repeat INR. The results for the stat PT/INR were not found in the resident ' s medical record. During an interview at 3:29 p.m. on 05/11/16, the Director of Nursing (DON) was asked for the results of the stat PT/INR. He reviewed the clinical record and stated that he would have to go look to see if the results were in her record in the medical records department. At 3:58 p.m. on 05/11/16, the DON confirmed he could not locate the lab results for the stat PT/INR in the resident ' s record and he had called the lab who completed the test. The lab faxed the results to the DON, which he provided on 05/11/16 at 3:44 p.m.",2019-05-01
4952,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,508,D,1,0,1MMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to obtain a physician ordered chest X-ray for Resident #75. This was true for one (1) of twelve (12) sampled residents. Resident Identifier: #75. Facility Census: 72. Findings include: a) Resident #75 A review of Resident #75's medical record at 9:10 a.m. on 05/11/16, found a progress note from her pulmonologist dated 10/14/15. This progress note indicated the pulmonologist wanted to obtain a chest X-ray in two (2) weeks to see if the resident ' s pneumonia had resolved. The pulmonologist sent back to the facility a printed physician's orders [REDACTED]. The attending physician also wrote, OK on the order to indicate that it was okay with him to obtain the X-ray as requested by the Pulmonologist. An interview with the Director of Nursing (DON) at 10:18 a.m. on 05/12/16, confirmed the facility failed to obtain the X-ray as ordered by the pulmonologist and approved by her attending physician. He indicated that he had contacted the pulmonologist's office to see if they had obtained the X-ray and they had not.",2019-05-01
4953,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,513,D,1,0,1MMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to maintain the results of a computed tomography (CT) scan of the head in Resident #68's medical record. This was found for one (1) of nine (9) residents reviewed. Resident identifier: #68. Facility census: 72. Findings include: a) Resident #68 On 05/16/16 at 2:30 p.m., a review of Resident #68's medical records revealed an admission date of [DATE]. Admission physician orders [REDACTED]. During an interview on 05/17/16 at 12:45 p.m., the Director of Nursing (DON) provided a copy of the report of the CT of the resident's head completed on 11/06/15. The DON verified the CT report was requested from the hospital and the hospital had faxed it to the facility on [DATE] at 11:38 a.m.",2019-05-01
4954,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,514,E,1,0,1MMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, resident interview, and staff interview, the facility failed to ensure medical records were complete and accurately documented for three (3) of nine (9) residents reviewed. The nurse who wrote Resident #68's admission orders [REDACTED]. Additionally, the reports for two (2) dermatology consults, one (1) cardiology consult, and one (1) neurologist ' s consult were not in the resident ' s medical records. A random observation found medications for five (5) residents (Residents #44, #40, #65, #19, and #37) signed as administered several hours prior to the actual administration times. Resident #8's treatment administration record (TAR) was signed for the application of a continuous positive airway pressure ([MEDICAL CONDITION]) nightly; however, the resident said it had not been offered since her admission. An inaccurate admission weight for Resident #8 was not corrected or noted as an error. Resident #10 was administered a onetime dose of insulin and the doses were not recorded on the medication administration record (MAR). Resident identifiers: #68, #44, #40, #65, #19, #37, #8 and #10. Facility census: 72. Findings include: a) Resident #68 On 05/16/16 at 2:30 p.m., a review of Resident #68's medical records revealed an admission date of [DATE]. The licensed nurse who wrote the resident ' s admission orders [REDACTED]. Additionally, Resident #68 had consultations with a dermatologist on two (2) different occasions (12/14/15 and 02/24/16) and one (1) consultation with a cardiologist (11/19/15) and one (1) consultation with a neurologist (11/19/15). None of the consultations could be located in Resident #68's medical record. During an interview on 05/16/16 at 12:45 p.m., after reviewing the resident ' s clinical records, the Director of Nursing confirmed the consultations were not in the resident ' s records. He also confirmed a licensed nurse did not sign the admission orders [REDACTED]. b) Pre-Signing of the Medication Administration Record (MAR) A review of the all MARs on the 100 hall beginning at 1:26 a.m. on 05/10/16, found the following areas of concern: -- Resident #19's dose of [MEDICATION NAME], scheduled at 6:00 a.m., was already initialed as given at the time of this review. -- Resident #44's 6:00 a.m. dose of [MEDICATION NAME] 10/325 was initialed as given at the time of this review. -- Resident #40's 6:00 a.m. dose of [MEDICATION NAME] was already initialed as given at the time of this review. -- Resident #65's 4:00 a.m. dose of [MEDICATION NAME] was already initialed as given at the time of this review. -- Resident #37's medication administration record found that her [MEDICATION NAME] R 5 units before meals, which was due at 6:00 a.m., was already initialed as given at the time of this review. An interview with Licensed Practical Nurse (LPN) #5, beginning at 1:40 a.m. and concluding at 1:51 a.m. on 05/10/16, revealed she had initialed the MAR early so that she would not forget to do it later. LPN #5 further stated, You should not initial the MAR or controlled substance sheet until the time of administration. c) Resident #8 1. Continuous Positive Airway Pressure (C-PAP) documentation A review of Resident #8's medical record at 12:55 p.m. on 05/10/16, found this resident, admitted to the facility on [DATE], had admission [DIAGNOSES REDACTED]. The resident had the capacity to make medical decisions and scored the maximum score of 15 on Her Brief Interview for Mental Status (BIMS) on her admission minimum data set (MDS), indicating she had no cognitive impairments. Further review of the record found a physician's order [REDACTED]. This order had a start date of 04/28/16. Review of the Treatment Administration Record (TAR) for the month of (MONTH) (YEAR) found her [MEDICAL CONDITION] initialed on the TAR every day, indicating it was applied to the resident and she wore it while sleeping. During an interview at 2:20 p.m. on 05/10/16, Resident #8 stated she had not worn her C-PAP since admitted to the facility. When asked why she had not been wearing her C-PAP, she stated she was waiting for staff to get authorization for its use. Observation noted the resident had a C-PAP machine in her room complete with a mask. The C-PAP machine sat on the resident ' s nightstand in the corner of her room and the mask was in a bag hanging around the hose and lodged between the wall and the nightstand. During an interview with Registered Nurse (RN) #51 at 4:27 p.m. on 05/10/16, she confirmed Resident #8 did have orders for a C-PAP. She indicated the machine was here when the resident arrived at the facility on 04/20/16, but she (the nurse) had to clarify the order for the settings, which she did on 04/28/16. She stated that as far as she knew they were putting it on her at night. She referred to the TAR, which indicated the nursing staff had been placing the C-Pap on Resident #8 at night. An additional interview with Resident #8 at 4:58 p.m. on 05/10/16, with RN #51 present, the resident was again asked if she had been using her C-PAP while at the facility. Resident #8 again stated that they had not been putting her C-PAP machine on because they were waiting on authorization. Resident #8 confirmed to RN #51 that she would like to start wearing her C-PAP at night if they would put it on her. RN #51 confirmed that nothing was wrong with Resident #8's memory. She confirmed she would know if they were putting it on her or not. She stated that she was not sure why staff were not putting it on her, but initialing that they were. 2. Weights Review of Resident #8's medical record at 12:55 p.m. on 05/10/16, found the following weights recorded in the electronic medical record: -- 04/20/16 316.8 pounds (lb) -- 04/27/16 373.6 lb -- 05/09/16 380.6 lb An interview with the Assistant Director of Nursing (ADON) at 4:42 p.m. on 05/10/16, revealed the resident's weight of 316.8 lb upon admission was not accurate. He stated that it was not possible for the resident to gain that much weight in one week. He indicated that review of the hospital records found the resident's weight on 04/27/16 of 373.6 lb was closer to her normal weight and her weight in the hospital. When asked what the practice was when an inaccurate weight was in the record, he stated it should be struck out as an error. He confirmed this weight was not struck out. d) Resident #10 Review of Resident #10's medical record at 9:45 a.m. on 05/16/16, found a onetime order dated 11/08/15 for 14 units of Humalog (insulin) for a blood sugar of 434. Review of Resident #10's MAR for (MONTH) (YEAR) found this medication was not documented on the MAR as administered. Review of the nursing progress notes found the following notes (typed as written): 11/08/15 4:40 p.m. Blood sugar was 434 at 4pm (4:00 p.m.) (name of physician) notified by RN supervisor. Order received for 14 units of humalog insulin sq (subcutaneously) now. Insulin administered by this nurse. 11/08/15 8:49 p.m. Blood sugar rechecked at 730 pm. (7:30 p.m.) 223. An interview with the Director of Nursing (DON) at 2:28 p.m. on 05/16/16, confirmed this medication was not documented on the MAR. He stated he knew the nurse administered it because of the nursing progress note written on that day.",2019-05-01
5448,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2015-06-26,156,D,0,1,7OP711,"Based on staff interview and review of the liability notices, the facility failed to ensure one (1) of three (3) residents, reviewed for the care area of liability notices and beneficiary appeal rights, received the notice of termination of Medicare services forty-eight (48) hours before the proposed end of services as required by the Centers for Medicare and Medicaid Services (CMS). Resident identifier: #13. Facility census: 71. Findings include: a) Resident #13 At 8:18 a.m. on 06/24/15, the care area of liability notices and beneficiary appeal rights were reviewed with Employee #29, the business office manager. Resident #13 was receiving Part A Medicare skilled services at the time of termination of benefits. The facility provided the resident's responsible party a copy of CMS form # . The form notified the responsible party the resident's skilled nursing services would end on 02/13/15. CMS form was signed by the responsible party on 02/12/15. This signature indicated the responsible party was notified that coverage of services would end on 02/13/15, and the responsible party had the right to appeal the decision of termination by the facility. Employee #29 was unable to locate any evidence the responsible party was contacted by any means, including telephone notification of termination of services, forty-eight (48) hours prior to termination of the services as required by CMS. Employee #29 stated, We do so many of them, I guess someone could have missed notifying her daughter. According to CMS reference letter S&C-09-20, issued on 01/09/2009, . The SNF (skilled nursing facility) is required to notify the beneficiary of the decision to terminate covered services (Generic Notice, CMS ) no later than 2 days before the proposed end of services . At 3:54 p.m. on 06/24/15, when the administrator was advised of the findings, he stated his business office manager had already told him about the issue.",2019-01-01
5449,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2015-06-26,157,D,0,1,7OP711,"Based on record review and staff interview, the facility failed to notify the attending physician for one (1) of six (6) residents reviewed for the care area of unnecessary medications, of a need to alter her treatment. The resident refused to have her blood drawn for an ordered laboratory (lab) test. The facility failed to notify the attending physician of the resident's refusal to determine how the physician wanted to proceed with her treatment. Resident identifier: #23. Facility census: 71. Findings include: a) Resident #23 A review of Resident #23's medical record, at 12:23 p.m. on 06/24/15, found a physician's order dated 06/11/15 for a Basic Metabolic Panel (BMP) on the morning of 06/12/15. Upon further review of the record, the results of the BMP, which was to be obtained on 06/12/15, could not be located. At 10:11 a.m. on 06/25/15, an Interview with the Assistant Director of Nursing (ADON) Registered Nurse (RN) #91, revealed the BMP ordered for Resident #23 on 06/12/15 was not obtained. When asked why the BMP was not obtained, the ADON stated, Because she refused to let them draw it. The ADON referred to a Lab log for 06/12/15. Resident #23's name was listed on this log. Under the draw site, the word Refused was written. The ADON was asked if Resident #23's attending physician was notified of her refusal. She reviewed the medical record and indicated the attending physician was not notified of the resident's refusal for the lab draw. An additional review of Resident #23's medical record, at 9:00 a.m. on 06/26/15, found the following physician's order dated 06/25/15, . Obtain BMP on 06/25/15 d/t (due to) missed lab on 06/12.",2019-01-01
5450,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2015-06-26,244,E,0,1,7OP711,"Based on the resident council president interview, review of the resident council meeting minutes, review of food temperature records, and staff interview, the facility failed to ensure grievances voiced by the facility's resident council were fully acted upon. When the resident group expressed a concern about food temperatures, the facility failed to address the concern fully practicable. This had the potential to affect more than an isolated number of residents. Resident identifier: #27. Facility census: 71. a) Resident #27 At 1:30 p.m. on 06/25/15, Resident #27, the resident council president, was interviewed. When asked if staff listened to and acted upon grievances from the council, the resident replied, No. The resident explained the facility listened to concerns, but they did not seem to do anything about them. Resident #27 stated the group had complained about the temperatures of the hot food, especially the evening meal temperatures, yet the temperatures had not improved. b) Review of the resident council meeting minutes found a meeting was held on 05/26/15. A concern expressed by the group was cold hot food temperatures, especially in the evenings. A resident council department response form for the concern, found the facility's response was, temp. (temperature) check done on 6/1 for dinner temp was 148 degrees at 5:10 when delivered to floor, will continue to monitor. There was no evidence the facility did anything else to address the group's concern, and no evidence of continued monitoring. c) The evening meal on 06/25/15 was observed. The facility's first food cart, for residents eating in their rooms, left the kitchen at 5:10 p.m. Prior to service in the dining room, Cook #13 placed the food in a steam table located inside the dining room. Residents eating in the dining room were served their meals directly from the steam table. At 5:35 p.m. on 06/25/15, residents in the dining room began receiving their meals d) At 5:50 p.m. on 06/25/15, Cook #13 was asked for the temperature log for the food served during the evening meal on 06/25/15. Cook #13 provided the log with the temperatures recorded as follows: -- Hot entree: 170 degrees at 4:20 -- Starch: 175 degrees at 4:15 p.m. -- Vegetable: 165 degrees at 4:20 p.m. -- Hot entree #2: 150 degrees at 4:15 p.m. These temperatures were obtained nearly an hour before the food left the kitchen for service in the rooms, and more than an hour before meal service began in the dining room. The log indicated Cook #13 obtained the temperatures. At 5:50 p.m. on 06/25/15, Cook #13 confirmed these temperatures were obtained when she placed the food on the steam table in the kitchen to serve the residents who ate in their rooms. She said she did not obtain a second set of temperatures when food was taken from the kitchen and placed on the steam table in the dining room. Review of the cold food items, recorded in the log, were as follows: -- Cake: 165 degrees at 4:00 p.m. -- Juice: 170 degrees at 4:16 p.m. -- Juice: 41 degrees, no time recorded. -- Milk: 21 degrees, no time recorded. The log indicated these temperatures were obtained by Dietary Aide (DA) #55. At 5:50 p.m. on 06/25/15, DA #55 was asked if the cake with icing was served at 165 degrees. Employee #55 stated, That was the temperature when I took the cake out of the oven. She said she did not obtain the temperatures of the cold food items at the time of service. Review of additional temperature logs for (MONTH) (YEAR), provided by the administrator at 8:00 a.m. on 06/27/15, found food temperatures were not always obtained: -- 06/02/15: the temperatures of the cold food items were not obtained for the evening meal. -- 06/03/15: temperatures for coffee, juice and milk were not obtained for breakfast. Temperatures of the beverages were not obtained for the noon meal. Temperatures of the dessert and beverages were not obtained for the evening meal. -- 06/04/15: temperatures of beverages were not obtained for the evening meal. -- 06/10/15: temperatures were not obtained for any items served at the evening meal. -- 06/14/15: temperatures were not obtained for the food items served at the evening meal. -- 06/21/15: temperatures were not obtained for the noon or evening meal, for food items. -- 06/22/15: temperatures were not obtained for breakfast or the noon meal served. -- 06/23/15: temperatures were not obtained for the evening meal. e) At 8:08 a.m. on 06/27/15, the administrator was asked how the facility monitored food temperatures of the evening meals, as there were omissions on the temperature log. The administrator confirmed the temperatures should have been recorded on the temperature logs to verify the temperatures of the food items at the time of service. He said he had a meeting with dietary staff about the temperatures, and the facility was working on the problems. At 8:30 a.m. on 06/27/15, Cook #13 confirmed she had no evidence to verify food temperatures were taken to ensure foods were cooked and held at temperatures that were hot enough upon receipt by the residents. She said she took temperatures to ensure this occurred, but she did not record the temperatures anywhere. The staff person acting as the dietary manager was unable to be interviewed, as she was not present at the time of the interviews on 06/27/15.",2019-01-01
5451,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2015-06-26,282,D,0,1,7OP711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident observation, family interview, and staff interview, the facility failed to provide services by qualified persons in accordance with the care plan for three (3) of fifteen (15) residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey. The care plan to position Resident #134 for comfort was not implemented. Resident #52 had a care plan to monitor behaviors and side effects related to the use of [MEDICAL CONDITION] medications was not implemented. The interventions related to pressure ulcers were not implemented for Resident #23. Resident identifiers #134, #52 and #23. Facility census 71. Findings include: a) Resident #134 Observations of Resident #134 having lunch in the dining room, on 06/23/15 at 12:35 p.m., revealed the resident was attempting to consume her meal. She was leaning to the left side of her wheelchair. When the resident was asked if she had difficulty standing up straight, she stated, Yes. The resident was observed in the same position until she finished her meal at 12:59 p.m. At no time did any staff member attempt to position Resident #134 into a more comfortable position. A review of Resident #134's care plan, on 06/23/15 at 6:00 p.m., revealed a care plan which indicated the resident exhibited or was at risk for alteration in comfort related to a history of recent right humerus fracture, [MEDICAL CONDITION] in her lower extremities, and [MEDICAL CONDITION]. The intervention in the care plan was to assist the resident to a position of comfort, utilizing pillows as an appropriate positioning device. This care plan was initiated on 02/09/15. @ Observation, on 06/23/15 at 6:16 p.m., revealed Resident #134 sitting in her wheelchair in her room. She was leaning to the left side of her chair. No pillows were observed in the resident's wheelchair to assist the resident to a comfortable position. When asked how long she had been leaning to her left side, she said, I came in here in (MONTH) (YEAR), and I had a problem since January, but the leaning has gotten worse over the last month. @ Observation of Resident #134, on 06/24/15 at 8:15 a.m., revealed the resident sitting in her wheelchair beside her bed. She was leaning to the left side of her chair. No pillows were observed in her wheelchair to assist the resident in being comfortable. @ Observation of Resident #134 at her doorway of her room, on 06/24/15 at 10:30 a.m., revealed the resident was leaning to the left side of her wheelchair. No pillows were observed to assist in the resident's comfort. Observation of Resident #134 at lunch in the dining room, on 06/24/15 at 12:30 p.m., revealed the resident was sitting in her wheelchair. She was leaning to the left side attempting to consume her meal. No pillow or other device was present in her wheelchair to assist the resident to a comfortable position. Staff were not observed attempting to reposition Resident #134 to a comfortable position. @ In an interview at the entrance of the dining room, on 06/24/15 at 12:35 p.m., with Resident #134's family member (FM), she was asked how long Resident #134 had been leaning to the left side when she was sitting in her wheelchair. The FM stated . has been leaning to the left side really bad in her wheelchair for about a month. She came to the facility leaning to the left side of her wheelchair in (MONTH) (YEAR). The FM stated, They finally are going to order some kind of pad to put in her chair to help her to sit up straighter. In an interview on 06/24/15 at 1:00 p.m., with the physical therapy-program manager (PT-PM) #84, she stated early this week the therapy department received a physical therapy (PT) request for Resident #134 to be evaluated. PT-PM stated the referral indicated the resident was having trouble last week in transferring. The PT-PM said when the occupational therapist (OT) evaluated Resident #134, the OT noticed the resident was not sitting straight in her wheelchair. The OT ordered a device to help the resident's core (mid-section of her body) to be able to stand up straighter. The OT stated she had started doing core exercises with the resident, and the resident could correct the position, but she was unable to hold the position for very long. @ In an interview on 06/24/15 at 1:45 p.m., with Nursing Assistant (NA) #43, she was asked what type of positioning assistance she provided to help Resident #134 from leaning to the left side. The NA stated, I remind the resident to sit up straight. The NA was asked if there was any other intervention used to prevent the resident from leaning. The NA shook her head no. @ In an interview with Licensed Practical Nurse (LPN) #12, on 06/24/15 1:33 p.m., the LPN was asked what interventions she used to prevent Resident #134 from leaning to the left side. The LPN stated, I tell the resident to reposition herself in the wheelchair. The LPN was asked if there was any other intervention she or the staff used to keep the resident in proper alignment. She replied, No, I just tell her to straighten her back up. The LPN was asked if there was something staff could do to prevent the resident from leaning to the left side. The LPN stated, No. At that time, the LPN was informed there was an intervention in the care plan to assist the resident to a position of comfort by utilizing pillows as positioning devices; however, the Kardex (the nursing assistants' means of identifying the care for to provide each resident) only said to assist the resident in repositioning. The intervention for positioning with pillows was not on the NAs' Kardex. LPN #12 looked at the care plan and the Kardex, and agreed. She confirmed staff had not been providing this intervention for Resident #134. The LPN also stated, The NAs would not have known to apply the pillow since the intervention was not brought over onto the Kardex. @ In an interview with OT #87, on 06/25/15 at 9:15 a.m., when asked about Resident #134's posture in the wheelchair, the OT said the resident had a pelvis deformity. The OT stated,The resident has been leaning to the left side since she was admitted here in (MONTH) (YEAR). @ Observation of Resident #134, on 06/25/15 at 11:40 a.m., revealed the facility had provided the resident a lap buddy to assist in positioning; however, the resident was still leaning to the left side of her wheelchair. b) Resident #52 Review of Resident #52's medical record, beginning on 06/24/15 at 2:30 p.m., found physician's orders [REDACTED]. Date Initiated: 07/27/10 and Revised on 01/29/14. The goals associated with this item were, (Resident's name) will not experience any exacerbation of depression or psychotic symptoms thru (sic) the next review. (Resident's name) will have the smallest most effective dose ([MEDICATION NAME] and [MEDICATION NAME]) without side effects thru (sic) next review. The interventions included, . Monitor for s/s (signs/symptoms) of depression and agitation. Monitor for side effects such as [MEDICAL CONDITION], dizziness, abnormal dreams, nausea, diarrhea, constipation, urinary frequency, weight gain or loss and myalgia. Complete behavior monitoring flow sheets, behaviors include excessive fear, consistently asking about meds. Document specific behaviors and any non-pharmacological interventions. This plan was initiated on 07/27/10. Review of Resident #52's medical record related to Behavior Monitoring and Interventions and Suspected Medication Side Effects sheets, for (MONTH) (YEAR) through (MONTH) (YEAR), found no behavioral monitoring sheets for (MONTH) (YEAR) and (MONTH) (YEAR). During an interview on 06/25/14 at 1:10 p.m., Resource Registered Nurse #98 and Assistant Director of Nursing (ADON) #91 reviewed Resident #52's medical record. They were unable to provide the behavior monitoring and side effect sheets for (MONTH) (YEAR) and (MONTH) (YEAR). They both agreed the interventions were not implemented for that period of time as directed by the care plan. c) Resident #23 A review of Resident #23's medical record at 9:27 a.m. on 06/24/15, found this [AGE] year old female was readmitted from the hospital on [DATE]. Her original admitted to the facility was 10/23/14. A review of Resident #23's care plan found a focus statement initiated on 10/24/15, with a target date of 09/17/15: Resident is at risk for additional skin breakdown as evidenced by fragile skin and limited mobility. With a goal of, The resident will show no signs of skin breakdown through the next review. The care plan contained the following interventions, 1. Assist resident in repositioning and turning as needed. 2. Encourage resident to consume all fluids during meals. 3. Evaluate for skin risk factors per protocol. 4. Float Heels While in bed. 5. Monitor skin for signs and symptoms of skin breakdown, i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily. 6. Observe skin condition with ADL (activities of daily living) care daily and report abnormalities. 7. Pressure redistribution surfaces to bed per protocol. 8. Pressure redistribution surfaces to chair per protocol. 9. Utilize positioning devices as appropriate to prevent pressure over bony prominence. 10. Weekly skin assessment by license nurse. An interview with Corporate Resource Nurse (CRN) Registered Nurse (RN) #98, at 1:34 p.m. on 06/24/15, revealed the facility protocol for identifying those resident's at risk for developing pressure ulcers was to look at the whole picture for each resident. She stated that included completing a Braden Scale for Predicting Pressure Sore Risk, looking at the the resident's nutritional status and bed mobility, and performing a weekly skin check to help identify problem areas which may need more attention. Review of Resident #23's medical record found a Braden scale completed on readmission to the facility on [DATE]. It identified Resident #23's nutrition as probably inadequate - eats only about half of any food offered. Review of the resident's meal consumption percentages for (MONTH) (YEAR), as calculated by the facility, found Resident #23 ate 25% or less of the meals provided 72% of the time, or 67 of the 93 meals provided. According to the records, this indicated Resident #23's nutrition was very poor- never eats a complete complete meal, rarely eats more than 1/3 of any food offered. The Braden scale, as completed, indicated the resident was a moderate risk for developing pressure ulcers. Resident #23 had another Braden Scale, completed on 06/12/15. It indicated her nutrition was Adequate - Eats over 1/2 of all meals. Review of Resident #23's meal percentages from 06/05/15 through 06/11/15 found that out of 21 meals provided, Resident #23 only ate 1/2 or more of the meals seven (7) times or 33% of the time. At the remaining 67% percent of the time, Resident #23 ate 25% or less, indicating poor nutrition status - never eats a complete meal rarely eats more than 1/3 of any food offered. The Braden scale, as completed, indicated the resident was at moderate risk for developing pressure ulcers. A Braden Scale completed on 06/19/15, indicated Resident #23's nutrition was Adequate - Eats over 1/2 of all meals. Review of her documented meal percentages from 06/05/15 through 06/18/15 found Resident #23 ate 1/2 of her meal or more on 12 of the 42 meals offered or 29% of the time. This indicated Resident #23's nutrition was poor - never eats a complete meal and rarely eats more than 1/3 of any food offered. The Braden scale, as completed, indicated the resident was at mild risk for developing pressure ulcers. During the interview with CRN-RN #98, at 1:34 p.m. on 06/24/15, she was asked if Resident #23's nutritional status on the three (3) Braden scales completed in (MONTH) were accurate. She reviewed each Braden scale and the documented meal percentages. CRN-RN #98 stated they were all inaccurate, as each should have been marked as poor nutritional status. CRN-RN #98 was asked if the resident's Braden Score would have been lower, indicating a higher risk of developing pressure ulcers, if the assessments had been completed accurately. She affirmed it would have decreased the scores and have shown a greater risk for developing pressure ulcers. When asked what other preventative measures for the development of pressure ulcers were put in place for Resident #23, CRN-RN #98 stated they did weekly skin checks every Sunday. She said Resident #23 should have had one completed on 06/07/15. When asked for the results of this skin check, CRN-RN #98 stated, It appears they did not do one on that date. Since the Braden Scales were inaccurate and the required skin check on 06/07/15 was not completed, the facility failed to fully implement the interventions on the resident's care plan. This was confirmed by CRN-RN #98.",2019-01-01
5452,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2015-06-26,309,G,0,1,7OP711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident observation, and resident interview, the facility failed to provide the necessary care and services to maintain or attain the highest practicable physical, mental and psychosocial well-being for three (3) of fifteen (15) residents reviewed during Stage 2 of the Quality Indicator Survey. A physician ordered urinalysis with culture and sensitivity (UA C&S) was not completed for Resident #23, to rule out a urinary tract infection [MEDICAL CONDITION]. She subsequently had worsening confusion, agitation, and a fall requiring an emergency room (ER) The [DIAGNOSES REDACTED]. The failure of the facility to obtain the lab when originally ordered resulted in a delay in treatment. This was determined as harm to the resident because her condition worsened and hospitalization was required. In addition, the facility failed to ensure an effective pain management program for Resident #26, who was receiving Hospice services. For Resident #134, the facility failed to provide services for positioning while in her wheelchair. Resident Identifiers: #23, #26, and #134. Facility Census: 71. Findings Include: a) Resident #23 A review of Resident #23's medical record, at 12:23 p.m. on 06/24/15, revealed a physician's orders [REDACTED]. The medical record contained no evidence the repeat UA C&S was obtained on 05/29/15 as ordered. Further review of Resident #23's medical record found a Physician & NP (Nurse Practitioner) & PA (Physician Assistant) Note dated 06/01/15 which was authored by NP #99. The note read, . Worsening confusion. I last saw the resident on 05/28, and ordered a UA C&S to be obtained at that time due to increased confusion even though she had just completed a 7 day course of [MEDICATION NAME] for a UTI (Urinary Tract Infection); however, it appears that the specimen was not obtained. This afternoon she is up in her power chair and is screaming about, getting out of here and actively trying to get out of the building. She is very confused today; . This afternoon, her son is with her at bedside; she is hysterically crying and asking him to take her home. She keeps repeating that she is feeling nervous; her son is requesting she be given a one time dose of medication for anxiety. Further review of the nursing progress notes, found the following notes all dated 06/01/15, -- 1:42 p.m., New order to obtain UA C&S due to confusion. Urine obtained and Sent to (name of lab). -- 9:42 p.m., Resident very confused, agitated and combative for most of the day. (name of attending physician) ordered [MEDICATION NAME] .5 f/(for) 1 (one) time dose which did not calm her down. Dr. (doctor) notified of such and told to send her out to ER (emergency room ). -- 9:47 p.m. Change in condition: Resident had been confused combative and yelling most of the day, resident stated she is leaving this place if she has to crawl. -- 11:02 p.m., ord (order) rec'vd (received) for [MEDICATION NAME] 250 mg (milligram) po (by mouth) bid (twice a day) X (times) 7 (seven) days & (and) [MEDICATION NAME] .5 mg tb X1 po now. -- Late entry for 6/1/15 at 8:16 a.m., (Resident Name) transferred to hospital- unplanned for evaluation and treatment via ambulance to (Name of Local Hospital) Physician notified to transfer (name of attending physician) Responsible Party notified of transfer (name of son) copy of advance directives sent. Resident had a mental status change with hallucinations. See transfer form for additional clinical findings. Additional review of the medical record found a discharge summary from a local hospital dated 06/04/15. The discharge summary indicated Resident #23 was admitted to the hospital on [DATE] with an admitting [DIAGNOSES REDACTED]. The discharge summary indicated Resident #23's confusion returned to baseline during her stay at the hospital. Review of accident reports for Resident #23 found she had a fall on 06/01/15 at 5:10 p.m. The incident report indicated the resident was found on the floor beside her bed. Her condition at the time of the fall was noted as confused, agitated, and combative. Review of Resident #23's physician's orders [REDACTED]. An interview with the Assistant Director of Nursing (ADON) Registered Nurse (RN) #91 at 1:27 p.m. on 06/24/15, confirmed the facility failed to obtain Resident #23's UA C&S on 05/29/15. She stated NP #99 identified the lab had not been obtained when she saw the resident for worsening confusion on 06/01/15. The ADON confirmed Resident #23's confusion continued to worsen until 06/01/15. The ADON also confirmed Resident #23 was sent to the ER and was admitted to the hospital on [DATE] related to her increased confusion/agitation and was admitted to he hospital with a [DIAGNOSES REDACTED]. b) Resident #26 Record review, on 06/24/15 at 9:00 a.m., found Resident #26 began receiving Hospice services on 10/31/14 for end of life care. The resident was receiving Hospice services for advanced stages of dementia. The most recent minimum data set (MDS), a quarterly MDS with an assessment reference date (ARD) of 05/05/15 indicated the following: -- Section B was coded the resident rarely ever understands others. -- Section C1000, indicated the resident's cognition was severely impaired. -- Section C1600 was coded there was no acute onset in mental status change. Review of the Medication Administration Record [REDACTED]. A physician's orders [REDACTED]. (For verbal patients) are you free of pain or hurting? If no, indicate response through chart code PI every day shift. The response on the MAR for every day for the months of March, April, (MONTH) and (MONTH) (YEAR) was a Y, indicating, the resident's response was, yes. [MEDICATION NAME] 5-325 was administered on (10) ten different occasions in (MONTH) (YEAR): -- 03/02/15 at 9:00 p.m. -- 03/03/15 at 9:00 p.m. -- 03/04/15 at 10:18 p.m. -- 03/05/15 at 10:00 p.m. -- 03/07/15 at 9:00 p.m. -- 03/12/15 at 10:38 p.m. -- 03/28/15 at 9:00 p.m. -- 03/29/15 at 8:00 p.m. -- 03/30/15 at 10:00 p.m. -- 03/31/15 at 10:00 p.m. [MEDICATION NAME] 5-325 was administered on fifteen (15) occasions in (MONTH) (YEAR): -- 04/01/15 at 10:00 p.m. -- 04/02/15 at 10:00 p.m. -- 04/03/15 at 9:50 p.m. -- 04/04/15 at 10:00 p.m. -- 04/05/15 at 10:00 p.m. -- 04/10/15 at 9:00 p.m. -- 04/11/15 at 9:00 p.m. -- 04/12/15 at 9:00 p.m. -- 04/13/15 at 9:00 p.m. -- 04/14/15 at 9:00 p.m. -- 04/16/15 at 10:00 p.m. -- 04/22/15 at 9:00 p.m. -- 04/27/15 at 10:00 p.m. -- 04/29/15 at 9:00 p.m. -- 04/30/15 at 9:00 p.m. [MEDICATION NAME] 5-325 mg. was administered on ten (10) occasions in (MONTH) (YEAR): -- 05/02/15 at 10:00 p.m. -- 05/03/15 at 9:00 p.m. -- 05/04/15 at 9:00 p.m. -- 05/05/15 at 9:00 p.m. -- 05/06/15 at 9:00 p.m. -- 05/08/15 at 9:00 p.m. -- 05/11/15 at 9:00 p.m. -- 05/13/15 at 9:00 p.m. -- 05/14/15 at 9:00 p.m. -- 05/25/15 At 9:00 p.m. On this occasion, the nurse providing the medication documented the effect of the medication after giving and indicated non-pharmacological interventions were used before giving the medication. The specific interventions were not indicated. As of 06/24/15, [MEDICATION NAME] 5-325 mg. was given on only one (1) day in June, on 06/19/15. The use of non-pharmacological interventions (but not the specific interventions) and the effect of the pain medication were documented by the nurse At 10:41 a.m. on 06/24/15, the assistant director of nursing (ADON) #91 was interviewed. The ADON was asked the following questions: -- How could the nursing staff ask Resident #26 if she was in pain when the MDS indicated the resident would be unable to comprehend this question? -- What were the non-pharmacological interventions attempted before administering the pain medications? -- Where is the evidence the facility was monitoring the effectiveness of the pain medication after administration? -- What was the location of the resident's pain? The ADON stated the nursing staff should have been completing a PRN pain management flow sheet every time a dose of [MEDICATION NAME] was administered. She found only one (1) occasion in which this flow sheet was completed. It was completed for the 06/19/15 dose of [MEDICATION NAME]. The ADON confirmed nursing staff had not been indicating the pain rating before administration, the non-pharmacological interventions used prior to administration of the pain medicine, the location of the pain, or the effectiveness of the pain medication. She also reviewed the nursing notes and could find no evidence of this information in the nursing notes. The ADON was also unable to explain how nursing staff could have interviewed the resident, due to her confusion, to determine if she was in pain. Review of the facility's pain management policy, revised on 01/02/14, found: Purpose - To maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain . 8. Patients receiving interventions for pain will be monitored for the effectiveness and side effects in providing pain relief. Document: 8.1 Effectiveness of PRN medications. 8.2 Ineffectiveness of routine or PRN medications including interventions, follow-up, and physician/medical provider notification; 8.3 Side effects, if present, and notification of physician/mid-level provider; 8.4 Non - pharmacological interventions and effectiveness . At 2:22 p.m. on 06/25/15, an interview with the ADON and Employee #98, a registered nurse (resource nurse), confirmed the facility had not followed the pain management policy. At the close of the survey on 06/26/15 at 12:30 p.m., facility staff had not provided evidence to substantiate the resident's pain was being effectively evaluated and managed. c) Resident #134 Observations of Resident #134 having lunch in the dining room, on 06/23/15 at 12:35 p.m., revealed the resident was attempting to consume her meal. She was leaning to the left side of her wheelchair. When the resident was asked if she had difficulty standing up straight, she stated, Yes. The resident was observed in the same position until she finished her meal at 12:59 p.m. At no time did any staff member attempt to position Resident #134 into a more comfortable position. A review of Resident #134's care plan, on 06/23/15 at 6:00 p.m., revealed a care plan that indicated the resident exhibited or was at risk for alteration in comfort related to a history of recent right humerus fracture, [MEDICAL CONDITION] in her lower extremities, and [MEDICAL CONDITION]. The intervention in the care plan was to assist the resident to a position of comfort, utilizing pillows as an appropriate positioning device. This care plan was initiated on 02/09/15. @ Observation, on 06/23/15 at 6:16 p.m., revealed Resident #134 sitting in her wheelchair in her room. She was leaning to the left side of her chair. No pillows were observed in the resident's wheelchair to assist the resident to a comfortable position. When asked how long she had been leaning to her left side, she said, I came in here in (MONTH) (YEAR), and I had a problem since January, but the leaning has gotten worse over the last month. @ Observation of Resident #134, on 06/24/15 at 8:15 a.m., revealed the resident sitting in her wheelchair beside her bed. She was leaning to the left side of her chair. No pillows were observed in her wheelchair to assist the resident in being comfortable. @ Observation of Resident #134 at her doorway of her room, on 06/24/15 at 10:30 a.m., revealed the resident was leaning to the left side of her wheelchair. No pillows were observed to assist in the resident's comfort. Observation of Resident #134 at lunch in the dining room, on 06/24/15 at 12:30 p.m., revealed the resident was sitting in her wheelchair. She was leaning to the left side attempting to consume her meal. No pillow or other device was present in her wheelchair to assist the resident to a comfortable position. No staff attempted to reposition Resident #134 to a comfortable position. @ In an interview at the entrance of the dining room, on 06/24/15 at 12:35 p.m., with Resident #134's family member (FM), she was asked how long Resident #134 had been leaning to the left side when she was sitting in her wheelchair. The FM stated . has been leaning to the left side really bad in her wheelchair for about a month. She came to the facility leaning to the left side of her wheelchair in (MONTH) (YEAR). The FM stated, They finally are going to order some kind of pad to put in her chair to help her to sit up straighter. In an interview on 06/24/15 at 1:00 p.m., with the physical therapy-program manager (PT-PM) #84, she stated early this week the therapy department received a physical therapy (PT) request for Resident #134 to be evaluated. PT-PM stated the referral indicated the resident was having trouble last week in transferring. The PT-PM said when the occupational therapist (OT) evaluated Resident #134; the OT noticed the resident was not sitting straight in her wheelchair. The OT ordered a device to help the resident's core (mid-section of her body) to be able to stand up straighter. The OT stated she had started doing core exercises with the resident, and the resident could correct the position, but she was unable to hold the position for very long. @ In an interview on 06/24/15 at 1:45 p.m., with nursing assistant (NA) #43, she was asked what type of positioning assistance she provided to help Resident #134 from leaning to the left side. The NA stated, I remind the resident to sit up straight. The NA was asked if there was any other intervention used to prevent the resident from leaning. The NA shook her head no. @ In an interview with Licensed Practical Nurse (LPN) #12, on 06/24/15 1:33 p.m., the LPN was asked what interventions she used to prevent Resident #134 from leaning to the left side. The LPN stated, I tell the resident to reposition herself in the wheelchair. The LPN was asked if there was any other intervention that she or the staff used to keep the resident in proper alignment. She replied, No, I just tell her to straighten her back up. The LPN was asked if there was something staff could do to prevent the resident from leaning to the left side. The LPN stated, No. At that time, the LPN was informed there was an intervention in the care plan to assist the resident to a position of comfort by utilizing pillows as positioning devices; however, the Kardex (the nursing assistants' means of identifying the care for to provide each resident) only said to assist the resident in repositioning. The intervention for positioning with pillows was not on the NAs' Kardex. LPN #12 looked at the care plan and the Kardex, and agreed. She confirmed staff had not been providing this intervention for Resident #134. The LPN also stated, The NAs would not have known to apply the pillow since the intervention was not brought over onto the Kardex. @ In an interview with OT #87, on 06/25/15 at 9:15 a.m., when asked about Resident #134's posture in the wheelchair, the OT said the resident had a pelvis deformity. The OT stated, The resident has been leaning to the left side since she was admitted here in (MONTH) (YEAR). @ Observation of Resident #134, on 06/25/15 at 11:40 a.m., revealed the facility had provided the resident a lap buddy to assist in positioning; however, the resident was still leaning to the left side of her wheelchair.",2019-01-01
5453,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2015-06-26,314,G,0,1,7OP711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #23, who was admitted to the facility without pressure ulcers, did not develop avoidable pressure ulcers after admission to the facility. The resident was identified at risk for developing pressure ulcers; however, the the facility failed to implement interventions to prevent pressure ulcers. This failure resulted in harm to the resident, as she developed four (4) avoidable deep tissue injury pressure ulcers after readmission to the facility. Resident Identifier: #23. Facility Census: 71. Findings Include: a) Resident #23 A review of Resident #23's medical record at 9:27 a.m. on 06/24/15, found this [AGE] year old female was readmitted from the hospital on [DATE]. Her original admitted to the facility was 10/23/14. The nursing readmission assessment, dated 06/05/15 at 12:50 a.m., indicated the resident had no skin impairments present upon her readmission to the facility on [DATE]. By 06/09/15, the resident had developed in-house acquired pressure ulcers. A review of Resident #23's care plan found a focus statement initiated on 10/24/14, with a target date of 09/17/15: Resident is at risk for additional skin breakdown as evidenced by fragile skin and limited mobility. With a goal of, The resident will show no signs of skin breakdown through the next review. The care plan contained the following interventions, 1. Assist resident in repositioning and turning as needed. 2. Encourage resident to consume all fluids during meals. 3. Evaluate for skin risk factors per protocol. 4. Float Heels While in bed. 5. Monitor skin for signs and symptoms of skin breakdown, i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily. 6. Observe skin condition with ADL (activities of daily living) care daily and report abnormalities. 7. Pressure redistribution surfaces to bed per protocol. 8. Pressure redistribution surfaces to chair per protocol. 9. Utilize positioning devices as appropriate to prevent pressure over bony prominence. 10. Weekly skin assessment by license nurse. Further review of Resident #23's medical record found a nurse progress note, dated 06/09/15 at 3:26 p.m. which read, Resident found to have three (3) small DTIs (Deep Tissue Injuries) and one moderately sized DT on coccyx and hips. It is believe (sic) that these wounds were present when resident returned from hospitalization . Additionally, on 06/09/15, Nurse Practitioner #99 saw Resident #23 and noted the four (4) DTIs, described as: Coccyx:DTI/Unstageable: 1.8 X 1.8 CM; intact dark purple skin; does no blanch;no open areas or drainage. L(Left) Upper Hip: DTI/Unstageable: 1 X 1 CM; intact dark purple skin; does not blanch; no open areas or drainage. R (Right) Hip: DTI/Unstageable: .8 X .8 CM; intact dark purple skin; does not blanch; no open areas or drainage. L (left) lower hip: DTI/Unstageable: 1X1 CM; intact dark purple skin; does not blanch; no open areas or drainage. Review of the Skin integrity sheets found Resident #23 had four (4) wounds discovered on 06/09/15. The wound care nurse described each of the wounds: -- DTI to Coccyx measuring 1.8 X 1.8 CM with intact deep purple skin. The skin integrity report indicated this wound was in house acquired. -- DTI to Left upper hip measuring 1 X 1 CM with intact deep purple skin. The skin integrity report indicated this wound was in house acquired. -- DTI to Right Hip measuring .8 X .8 CM with intact deep purple skin. The skin integrity report indicated this wound was in house acquired. -- DTI to left lower hip measuring 1 X 1 CM with intact deep purple skin. The skin integrity report indicated this wound was in house acquired. An interview with Corporate Resource Nurse (CRN) Registered Nurse (RN) #98, at 1:34 p.m. on 06/24/15, revealed the facility protocol for identifying residents at risk for developing pressure ulcers was to look at the whole picture for each resident. She stated it included completing a Braden Scale for Predicting Pressure Sore Risk, looking at the the resident's nutritional status and bed mobility, and performing a weekly skin check to help identify problem areas which may need more attention. Review of Resident #23's medical record found a Braden scale completed on readmission to the facility on [DATE]. It identified Resident #23's nutrition as probably inadequate - eats only about half of any food offered. Review of the resident's meal consumption percentages for (MONTH) (YEAR), as calculated by the facility, found Resident #23 ate 25% or less of the meals provided 72% of the time, or 67 of the 93 meals provided. According to the records, this indicated Resident #23's nutrition was very poor- never eats a complete complete meal, rarely eats more than 1/3 of any food offered. The Braden scale, as completed, indicated the resident was a moderate risk for developing pressure ulcers. Resident #23 had another Braden Scale, completed on 06/12/15. It indicated her nutrition was Adequate - Eats over 1/2 of all meals. Review of Resident #23's meal percentages from 06/05/15 through 06/11/15 found that out of 21 meals provided, Resident #23 only ate 1/2 or more of the meals seven (7) times or 33% of the time. At the remaining 67% percent of the time, Resident #23 ate 25% or less, indicating poor nutrition status - never eats a complete meal rarely eats more than 1/3 of any food offered. The Braden scale, as completed, indicated the resident was at moderate risk for developing pressure ulcers. A Braden Scale completed on 06/19/15, indicated Resident #23's nutrition was Adequate - Eats over 1/2 of all meals. Review of her documented meal percentages from 06/05/15 through 06/18/15 found Resident #23 ate 1/2 of her meal or more on 12 of the 42 meals offered or 29% of the time. This indicated Resident #23's nutrition was poor - never eats a complete meal and rarely eats more than 1/3 of any food offered. The Braden scale, as completed, indicated the resident was at mild risk for developing pressure ulcers. During the interview with CRN-RN #98, at 1:34 p.m. on 06/24/15, she was asked if Resident #23's nutritional status on the three (3) Braden scales completed in (MONTH) were accurate. She reviewed each Braden scale and the documented meal percentages. CRN-RN #98 stated they were all inaccurate, as each should have been marked as poor nutritional status. CRN-RN #98 was asked if the resident's Braden Score would have been lower, indicating a higher risk of developing pressure ulcers, if the assessments had been completed accurately. She affirmed it would have decreased the scores and have shown a greater risk for developing pressure ulcers. When asked what other preventative measures for the development of pressure ulcers were put in place for Resident #23, CRN-RN #98 stated they did weekly skin checks every Sunday. She said Resident #23 should have had one completed on 06/07/15. When asked for the results of this skin check, CRN-RN #98 stated, It appears they did not do one on that date. She stated the first note about any skin checks or concerns was on 06/09/15, when it was noted Resident #23 had four (4) deep tissue injuries identified during ADL care. CRN -RN #98 was asked if Resident #23 was compliant with turning and repositioning. She reviewed the the medical record and found no evidence Resident #23 was non-compliant with turning and repositioning. When asked what types of interventions were put in place to prevent residents from developing pressure ulcers, CRN-RN #98 stated upon admission each resident was placed on a pressure reducing mattress. She stated it was standard protocol to use a pressure reliving mattress to all beds and a pressure relieving cushion to all wheel chairs regardless of the resident's risk for developing pressure ulcers. CRN-RN #98 stated. they floated Resident #23's heels while in bed, and the resident did not develop pressure ulcers to her heels. CRN-RN #98 indicated she could find no other individualized interventions, for the prevention of pressure ulcers for Resident #23, between her readmission on 06/04/15 and 06/09/15, when the pressure ulcers were identified. In addition, since the Braden Scales were inaccurate and the required skin check on 06/07/15 was not completed, the facility failed to fully implement interventions to prevent the development of pressure ulcers for the resident. This was confirmed by CRN-RN #98.",2019-01-01
5454,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2015-06-26,329,E,0,1,7OP711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure three (3) of six (6) Stage 2 Quality Indicator Survey (QIS) sample residents, reviewed for unnecessary medications, were free of unnecessary medications. The facility failed to implement non-pharmacological interventions, monitoring of behaviors and/or monitoring of potential side effects for Residents #81 and #52, who received [MEDICAL CONDITION] medications. There was no clinical rationale for not attempting a gradual dose reduction of a [MEDICAL CONDITION] medication for Resident #75. Resident identifiers: #81, #52, and #75. Facility census: 71. Findings include: a) Resident #81 A medical record review for Resident #81, on 06/25/15 at 11:15 a.m., revealed physician's orders [REDACTED]. -- [MEDICATION NAME] 0.25 mg (milligrams), give one tablet by mouth two times a day for AEB (As Evidenced By): crying, hand wringing, restlessness, related to anxiety state ., [MEDICATION NAME] 0.5 mg - give one tablet by mouth at bedtime for AEB: crying, hand wringing, restlessness, related to anxiety state . -- [MEDICATION NAME] give 0.5 mg by mouth for AEB: crying, hand wringing, restlessness, related to anxiety state (MONTH) give as needed two times daily and [MEDICATION NAME] solution 2 mg/ml (milliliters) give 0.25 mg sublingually every two hours as needed for agitation- hitting and/or throwing self into the floor. In addition, review of the resident's Medication Administration Records (MARs), for (MONTH) (YEAR) through (MONTH) (YEAR), revealed the resident received the as needed (PRN) [MEDICATION NAME] 0.5 mg by mouth every night at 8:00 p.m. or 9:00 p.m. There was no evidence of the use of non-pharmacological interventions prior to the use of the medication, and no monitoring of behaviors since (MONTH) (YEAR). The last documented use of [MEDICATION NAME] 0.25 ml was on 02/06/15 at 9:00 p.m. On 06/25/15 at 12:15 p.m., the resident's medical records were reviewed with the Assistant Director of Nursing (ADON) #91 and Resource Registered Nurse (RRN) #98. On 06/25/15 at 12:25 p.m., a progress note was written by RRN #98, after the unnecessary medication concern was brought to the attention of the facility during the survey: . Discussed with MD (medical director) concerning [MEDICATION NAME] SL (sublingually) only given once in past three months. Reviewed behavior medication with MD and being on two anti-anxiety meds. New orders received to discontinue all [MEDICATION NAME] and [MEDICATION NAME] 5 mg (milligrams) po (by mouth) BID (twice daily) scheduled. NP (Nurse Practitioner) to follow up with resident on Monday . b) Resident #52 Review of Resident #52's medical record, beginning on 06/24/15 at 2:30 p.m., found physician's orders [REDACTED]. Date Initiated: 07/27/10 and Revised on 01/29/14. The goals associated with this item were, (Resident's name) will not experience any exacerbation of depression or psychotic symptoms thru (sic) the next review. (Resident's name) will have the smallest most effective dose ([MEDICATION NAME] and [MEDICATION NAME]) without side effects thru (sic) next review. The interventions included, . Monitor for s/s (signs/symptoms) of depression and agitation. Monitor for side effects such as [MEDICAL CONDITION], dizziness, abnormal dreams, nausea, diarrhea, constipation, urinary frequency, weight gain or loss and myalgia. Complete behavior monitoring flow sheets, behaviors include excessive fear, consistently asking about meds. Document specific behaviors and any non-pharmacological interventions. This plan was initiated on 07/27/10. Review of Resident #52's medical record related to Behavior Monitoring and Interventions and Suspected Medication Side Effects sheets, for (MONTH) (YEAR) through (MONTH) (YEAR), found no behavioral monitoring sheets for (MONTH) (YEAR) and (MONTH) (YEAR). During an interview on 06/25/14 at 1:10 p.m., Resource Registered Nurse #98 and Assistant Director of Nursing (ADON) #91 reviewed Resident #52's medical record. They were unable to provide the behavior monitoring and side effect sheets for (MONTH) (YEAR) and (MONTH) (YEAR). They both agreed the behaviors, non-pharmacological interventions, and side effects were not monitored in (MONTH) (YEAR) and (MONTH) (YEAR). c) Resident #75 Review of the care area of unnecessary medications at 1:30 p.m. on 06/24/15 found the resident was receiving [MEDICATION NAME] 50 milligrams (mgs) at bedtime for a [DIAGNOSES REDACTED]. Review of the most recent consulting pharmacist's report, dated 05/06/15, found the following recommendation: (Name of Resident) is due for annual review of [MEDICATION NAME] 50 mg at bedtime for [MEDICAL CONDITION] with no attempts at reduction in the previous two (2) years. She is also receiving [MEDICATION NAME] 0.5 mg twice daily for anxiety. The pharmacists' recommendation was: Please review [MEDICATION NAME] and [MEDICATION NAME] at the current dose. If therapy is to continue of [MEDICATION NAME] and [MEDICATION NAME], please provide rationale describing a dose reduction as clinically contraindicated. On 06/03/15, the physician declined the gradual dose reduction (GDR) and responded with the following: The resident has had more episodes of crying and despair. Medical record review found no evidence of increased crying and despair. At 2:46 p.m. on 06/24/15, the assistant director of nursing, (ADON) reviewed the resident's records and confirmed she was also unable to find any evidence of increased crying and despair. She also reviewed the nurses' notes and found no documentation of increased behaviors. The facility completed a behavior monitoring sheet for (MONTH) (YEAR). It reflected the resident exhibited no behaviors for the entire month of (MONTH) (YEAR). The ADON said nursing staff did not complete behavior monitoring sheets for (MONTH) (YEAR) or (MONTH) (YEAR). As of 06/24/15, the (MONTH) (YEAR) behavior monitoring sheets also indicated no episodes of increased behaviors. Review of the physician's progress notes found no documentation of any increased behaviors when the resident was seen by the physician on 02/23/15, 03/02/15 and 04/28/15. At 4:50 p.m. on 06/25/15, Licensed Practical Nurse (LPN) #44, the resident's LPN, stated she had not noticed any increase in the resident's behaviors. At 4:55 p.m. on 06/25/15, Nursing Assistant (NA) #45, the resident's NA, also said she had not noticed any increase in the resident's behaviors.",2019-01-01
5455,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2015-06-26,371,F,0,1,7OP711,"Based on observation, record review, staff interview, and policy review, the facility failed to ensure foods were stored, prepared, and served in a safe and sanitary manner. Foods were found unlabeled and undated in the refrigerator, cooler, and freezer in the kitchen. Unpasteurized eggs were stored on the top shelf in the cooler, over ready to eat foods. Staff did not fully restrain hair when working in the dining room/kitchen. Staff handled food items with gloves, which had been used to handle non-food items. Staff were not monitoring food temperatures at the point of service. The toaster in the nutritional pantry had an accumulation of bread crumbs inside and on the tray of the toaster. These practices had the potential to affect all residents residing in the facility who were served foods from the dietary department and/or the nutritional Pantry. Facility census 71. Findings include: a) During the initial tour of the kitchen, on 06/23/15 at 12:00 p.m., with Cook #13, sanitation infractions identified included: 1. The refrigerator had one (1) pound of margarine which was opened, unlabeled, undated, and exposed to the refrigerator air. 2. Inside the cooler, there were 18 non-pasteurized large grade A eggs on the top shelf. These eggs were stored over cooked bacon, a five (5) pound bag of garlic, eight (8) ounces of whole mushrooms, and 2.5 pounds of cheese. At that time, the cook acknowledged the eggs should not be stored above the ready to eat foods items, and moved the eggs to the bottom shelf. 3. In the freezer was a one (1) pizza roll sitting on top of one (1) pizza roll in an opened bag exposed to the freezer air. In addition, there was one (1) bag of rolls in a clear plastic bag which was undated and unlabeled. b) A review of the facility's policy for food handling, on 06/25/15 at 6:00 p.m., revealed the refrigerated/frozen storage policy stated all foods were to be labeled with the name of the product, the date received, and the use by date once opened. This policy also stated raw eggs or egg products were to be stored on lower shelves, and not above any cooked or ready to eat products. The food handling policy also revealed unpasteurized eggs were not served. c) Observation of the nutritional Pantry, with Ward Clerk (WC) #25 on 06/24/15 at 8:02 a.m., revealed a commercial toaster with an accumulation of crumbs inside the toaster, and on the slide tray underneath the toaster. WC #25 stated, This toaster needs cleaned. The WC was asked who was responsible for cleaning the toaster. WC #25 replied, I think the kitchen. WC #25 took the toaster to the kitchen, and asked Dietary Aide (DA) #23 if it was the responsibility of kitchen staff to clean the toaster in the nutritional room. DA #23 stated she had never cleaned the toaster. WC #23 stated, The Administrator told me to tell the kitchen staff to clean the toaster. A review of the Pantry/nourishment room sanitation policy revealed food storage and service equipment were to be routinely cleaned by designated staff. In an interview on 06/25/15 at 9:40 a.m., the administrator stated, The dietary department is responsible for cleaning the toaster. d) Observation of the dinner meal, on 06/25/15 at 5:45 p.m., found Nursing Assistant (NA) #63's hair was sticking out the back of her hairnet. She was in front of the steam table, turning around repeatedly. NA #63 walked behind the steam table, then went into the kitchen area and returned to the dining room with utensils for a resident. When discussed with Cook #13 and DA #55, both agreed NA #63 should have her hair fully restrained by her hairnet. . e) On 06/24/2015 at 12:26:28 p.m., observations of the lunch service in the main dining room, from 12:10 p.m. to 12:25 p.m., noted DA #23 was wearing gloves. She was putting slices of bread and bowls of salad on trays to be served to residents seated in the dining room. With both hands, DA #23 handled a pitcher handed to her by one of the staff who was serving in the dining room. She sat the pitcher down and continued to handle slices of bread with her gloved hands. The bread was not wrapped and she had direct contact with the food. She then took the pitcher to the kitchen to get chocolate milk. As she returned to the tray line, she removed her gloves and donned a new pair, but held the fingers of the gloves in her hand after she removed them from the box of gloves. As she quickly donned the gloves, especially the fingers of the gloves, came in contact with her right forearm arm. She continued to handle the slices of bread with the gloves, as well as bowls of salad and fruit. She primarily had contact with the bowls with her left hand, but on occasion, would hold one in her right hand - the hand she used to handle the bread. f) At 1:30 p.m. on 06/25/15, Resident #27, the resident council president, was interviewed. The resident stated the resident group had complained about the temperatures of the hot food, especially the evening meal temperatures, yet the temperatures had not improved. Review of temperature logs for (MONTH) (YEAR), provided by the administrator at 8:00 a.m. on 06/27/15, found food temperatures were not always obtained: -- 06/02/15: the temperatures of the cold food items were not obtained for the evening meal. -- 06/03/15: temperatures for coffee, juice and milk were not obtained for breakfast. Temperatures of the beverages were not obtained for the noon meal. Temperatures of the dessert and beverages were not obtained for the evening meal. -- 06/04/15: temperatures of beverages were not obtained for the evening meal. -- 06/10/15: temperatures were not obtained for any items served for the evening meal. -- 06/14/15: temperatures were not obtained for the food items served for the evening meal. -- 06/21/15: temperatures were not obtained for the noon or evening meal, for food items. -- 06/22/15: temperatures were not obtained for breakfast or the noon meal served. -- 06/23/15: temperatures were not obtained for the evening meal. At 8:08 a.m. on 06/27/15, the administrator was asked how the facility monitored food temperatures of the evening meals, as there were omissions on the temperature log. The administrator confirmed the temperatures should have been recorded on the temperature logs to verify the temperatures of the food items. He said he had a meeting with dietary staff about the temperatures and the facility was working on the problems. .",2019-01-01
6168,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2015-05-28,241,D,1,0,25M511,"Based on observation, resident interview, and staff interview, the facility failed to provide care in a manner, which maintained dignity for two (2) of eight sampled residents (#14 and #71) and one (1) resident (#26) identified during a random opportunity for discovery. Staff transferred Resident #14 by pulling up on the back of her pants. Residents #71 and #26 were not served meals in their rooms at the same time as their roommates. Resident identifiers: #14, #71 and #26. Facility census: 72. Findings include: a) Resident #14 During an observation, on 05/28/15 at 1:15 p.m., Employee #64, a nursing assistant (NA), informed the hospice nurse Resident #14 required two (2) people to transfer from her wheelchair to the bed. The NA also informed the hospice nurse the resident did not always bear weight. The NA and nurse each placed one (1) arm beneath one (1) of the resident's arms at the axilla (armpit), and the NA pulled up on the back of the resident's pants for added support. They dragged the resident backwards, while the resident made sliding (skate like) motions with her feet. The resident did not provide weight bearing support. Review of the medical record revealed a Kardex (care plan for nursing assistants) and comprehensive care plan, which required staff utilize a gait belt for transfers. An interview with the administrator, on 05/28/15 at 1:45 p.m., confirmed the requirement to transfer Resident #14 utilizing a gait belt, and acknowledged staff had transferred the resident in an undignified manner. b) Resident #71 During a dinner observation on 05/26/15, Resident #71 was in her room. The resident's roommate had consumed half of her meal. Upon inquiry as to whether she was done, Resident #71 related she had not received her tray. Another dining observation, at dinner on 05/27/15, revealed Resident #71 again had not received her tray. She was conversing with a NA, and in an angry tone said, Where is my tray, I didn't get my tray. The resident's roommate had eaten half of her food. A follow-up interview with Resident #71, on 05/28/15 at 8:15 a.m., revealed her trays were often late, and sometimes she had to wait a half hour after the roommate received her meal. c) Resident #26 During a random opportunity for observation at dinner on 05/27/15, Resident #26 was seated in her wheelchair in her room. The resident's roommate was eating her meal, and had consumed most of her meal. Only a few bites of food remained on her tray. Resident #26 related she was hungry, and indicated she was not looking at her roommate, so that the wait would be more tolerable. d) An interview with the administrator, on 05/28/15 at 1:45 p.m., confirmed Residents #71 and #26 should have received their meals at the same time as their roommates.",2018-05-01
6169,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2015-05-28,315,D,1,0,25M511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure two (2) of three (3) residents observed were provided urinary system care and/or incontinence care by methods which prevented infections to the extent possible. Staff failed to utilize proper hand hygiene, linen handling, and other sanitary techniques when providing care. Resident identifiers: #5 and #14. Facility census: 72. Findings include: a) Resident #5 On 05/28/15 at 9:00 a.m., Resident #5 said he had a [MEDICATION NAME] about six (6) to eight (8) months ago. He said he had recurrent urinary tract infections, stating he could tell when he had an infection because he had some pain. The resident also related the [MEDICATION NAME] sometimes leaked. Review of the medical record revealed physician's orders [REDACTED].#5 was treated for [REDACTED]. Upon request, Resident #5 allowed an observation of the [MEDICATION NAME] care on 05/27/15 at 9:43 a.m. Nursing Assistant (NA) #50 gathered supplies and placed the wash cloths on the back of the commode. She washed her hands, donned gloves, and then placed the washcloths in the sink basin to wet them. After wringing the washcloths, by squeezing with her right hand and pushing the washcloths against the sink, the NA placed the cloths in a dry wash basin. She placed the basin on the over-the-bed table. When the NA was positioning the resident for care, the leg rests which were at the foot of the bed, fell over. The NA picked up the leg rests, and then continued with care without changing her gloves or performing hand hygiene. She placed a plastic bag on the bed, obtained paper towels, and a graduate. The NA placed the Foley drainage bag on the floor with no barrier beneath, and then quickly picked it up. She drained the urine into the graduate, poured the urine into the commode, obtained a sprayer from the wall behind the commode, and rinsed out the graduate. The NA returned to the bedside and checked the [MEDICATION NAME] site. She stated the bag and catheter were not due to be changed until the next day. The NA placed the washcloths in a bag, placed the wash basin in a different bag, and then stored the basin on the floor of the resident's shower. The NA then removed her gloves and washed her hands; however, she turned off the faucet with her bare hand, contaminating her hand. A subsequent observation of [MEDICATION NAME] care, on 05/28/15 at 10:15 a.m., revealed a wash basin in the sink, and washcloths draped over the side of the sink. NA #50 placed a bag of supplies and an empty bag for garbage at the foot of the bed. During [MEDICATION NAME] care, the NA obtained a 4 x 4 individually wrapped gauze package from the bag. She moistened the gauze in the basin of water, which contained peri-wash, and cleansed the stoma and peri-wound area. The NA then washed across the stoma area again, with the same gauze. Licensed practical nurse (LPN) #28 assisted the NA. During the dressing change, the resident related NA #50 routinely provided his [MEDICATION NAME] care. After cleansing the wound, the NA secured the [MEDICATION NAME] appliance. During an interview immediately following, the NA related she had read the procedure the night before to ensure she completed the procedure correctly. With further inquiry, the nursing assistant confirmed placing the washcloths on the back of the commode, the side of the sink, and in an unsanitized sink provided a potential for cross contamination. b) Resident #14 During an incontinence care/perineal care observation, on 05/28/15 at 1:15 p.m., NA #64 donned gloves and filled a basin with water. She turned off the faucet with the gloved hands, placed washcloths in the wash basin, utilizing the same gloves. She continued the process, placing a plastic bag at the foot of the bed. The NA obtained peri-wash from the drawer and placed it on the plastic bag. Without changing gloves and/or performing hand hygiene, the NA provided peri-care. She removed the lid from the peri-wash, sprayed a wash cloth and cleansed Resident #14's perineal area. The NA obtained a second cloth, picked up the spray bottle containing peri-wash, with the same contaminated gloves, and cleansed the residents buttock's and anal area. Without drying the resident, the NA applied a clean brief and dressed Resident #14. The NA, interviewed immediately after the incontinence care observation, related she did not have a wash cloth to dry the resident. She also confirmed she should have used hand hygiene when transitioning from a dirty to clean area/task, and confirmed the potential for cross contamination. The NA also acknowledged the potential for infection from a moist environment. Review of the infection control line listing revealed Resident #14 was treated for [REDACTED]. The perineal care (peri-care) policy, reviewed on 05/28/15 at 2:00 p.m., noted to dry perineum thoroughly using a clean towel . c) An interview with the administrator on 05/28/15 at 3:00 p.m., and the director of nursing at 3:45 p.m., confirmed staff utilized improper hygiene and other techniques when performing perineal care and [MEDICATION NAME] care, creating a potential for cross contamination and the transmission and development of infection.",2018-05-01
6170,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2015-05-28,323,D,1,0,25M511,"Based on observation, medical record review, and staff interview, the facility failed to ensure one (1) of eight (8) sampled residents was as free as possible from accident hazards over which the facility had control. An assistive safety device (gait belt), as required by the resident's care plan, was not used when the resident was transferred from her wheelchair to the bed. Resident identifier: #14. Facility census: 72. Findings include: a) Resident #14 During an observation, on 05/28/15 at 1:15 p.m., Nurse Aide (NA) #64 informed the hospice nurse that Resident #14 required two (2) people to transfer from her wheelchair to the bed. NA #64 also informed the hospice nurse the resident did not always bear weight. NA #64 and the hospice nurse each placed one (1) arm beneath one (1) of the resident's arms at the axilla (armpit), and NA #64 pulled up on the back of the resident's pants for added support. They dragged the resident backwards, while the resident made sliding (skate like) motions with her feet. The resident did not provide weight bearing support. Review of the medical record revealed a Kardex (care plan for nursing assistants) and comprehensive care plan which required staff utilize a gait belt for transfers. An interview with NA #55, on 05/28/15 at 3:45 p.m., confirmed facility practice, as well as the resident's care plan, required the use of a gait belt for Resident #14. In addition, NA #55 related if a resident did not bear weight, the individual should be evaluated for use of a lift. An interview with the administrator, on 05/28/15 at 1:45 p.m., confirmed Resident #14 should have been transferred using a gait belt. The administrator acknowledged the staff transferred Resident #14 in an unsafe manner.",2018-05-01
6171,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2015-05-28,325,D,1,0,25M511,"Based on record review and staff interview, the facility failed to evaluate and address the nutritional needs of one (1) of eight (8) residents reviewed for nutrition during a complaint investigation. The facility did not identify the need to assess the resident's nutritional status to determine appropriate interventions when the resident experienced a significant weight loss. Resident identifier: #73. Facility Census: 72 Findings include: a) Resident #73 On 05/27/15 at 10:30 a.m., a review of Resident #73's medical record revealed the resident weighed 82 pounds on 03/06/15 and 78 pounds on 04/03/15. This represented a significant weight loss of 5% between 03/06/15 and 04/03/15. There was no evidence the facility identified the resident had a significant weight loss. The resident's nutritional status was not assessed and interventions to address the weight loss were not implemented. In addition, there was no evidence the physician was notified of the resident's weight loss. An interview was conducted, on 05/28/15 at 3:31 p.m., with Employee #92, the Assistant Director of Nursing. She verified the physician was not contacted; the resident was not assessed, and nutritional interventions to address the weight loss were not implemented.",2018-05-01
6172,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2015-05-28,441,F,1,0,25M511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical and facility record reviews, policy review, resident interview, staff interview, and review of the Centers for Disease Control and Prevention (CDC-P) guidelines for effective hand washing, the facility failed to maintain an infection control program to prevent, to the extent possible, the development and transmission of disease and infection. Staff failed to follow isolation precautions, failed to perform hand hygiene when indicated, failed to use techniques to reduce the spread of infection when providing incontinence and [MEDICATION NAME] care, and did not properly handle linen when providing resident care. Three (3) of eight (8) sample residents, plus eleven (11) additional residents identified during random opportunities for discovery, were affected; however, the practices had the potential to affect all facility residents. Resident identifiers: #5, #14, #71, #70, #66, #64, #53, #52, #30, #48, #60, #54, #38, and #46. Facility census: 72. Findings include: a) Resident #5 On 05/28/15 at 9:00 a.m., the resident said he had a [MEDICATION NAME] about six (6) to eight (8) months ago. He said he had recurrent urinary tract infections, stating he could tell when he had an infection because he had some pain. The resident also related the [MEDICATION NAME] sometimes leaked. Review of the medical record revealed physician's order [REDACTED].#5 was treated for [REDACTED]. Upon request, Resident #5 allowed an observation of the [MEDICATION NAME] care on 05/27/15 at 9:43 a.m. Nursing Assistant (NA) #50 gathered supplies and placed the wash cloths on the back of the commode. She washed her hands, donned gloves, and then placed the washcloths in the sink basin to wet them. After wringing the washcloths, by squeezing with her right hand and pushing the washcloths against the sink, the NA placed the cloths in a dry wash basin. She placed the basin on the over-the-bed table. When the NA was positioning the resident for care, the leg rests which were at the foot of the bed, fell over. The NA picked up the leg rests, and then continued with care without changing her gloves or performing hand hygiene. She placed a plastic bag on the bed, obtained paper towels, and a graduate. The NA placed the Foley drainage bag on the floor with no barrier beneath, and then quickly picked it up. She drained the urine into the graduate, poured the urine into the commode, obtained a sprayer from the wall behind the commode, and rinsed out the graduate. The NA returned to the bedside and checked the [MEDICATION NAME] site. She stated the bag and catheter were not due to be changed until the next day. The NA placed the washcloths in a bag, placed the wash basin in a different bag, and then stored the basin on the floor of the resident's shower. The NA then removed her gloves and washed her hands; however, she turned off the faucet with her bare hand, contaminating her hand. A subsequent observation of [MEDICATION NAME] care, on 05/28/15 at 10:15 a.m., revealed a wash basin in the sink, and washcloths draped over the side of the sink. NA #50 placed a bag of supplies and an empty bag for garbage at the foot of the bed. During [MEDICATION NAME] care, the NA obtained a 4 x 4 individually wrapped gauze package from the bag. She moistened the gauze in the basin of water, which contained peri-wash, and cleansed the stoma and peri-wound area. The NA then washed across the stoma area again, with the same gauze. Licensed practical nurse (LPN) #28 assisted the NA. During the dressing change, the resident related NA #50 routinely provided his [MEDICATION NAME] care. After cleansing the wound, the NA secured the [MEDICATION NAME] appliance. During an interview immediately following, the NA related she had read the procedure the night before to ensure she completed the procedure correctly. With further inquiry, the nursing assistant confirmed placing the washcloths on the back of the commode, the side of the sink, and in an unsanitized sink provided a potential for cross contamination. b) Resident #14 During an incontinence care/perineal care observation, on 05/28/15 at 1:15 p.m., NA #64 (NA) donned gloves and filled a basin with water. She turned off the faucet with the gloved hands, placed washcloths in the wash basin, utilizing the same gloves. She continued the process, placing a plastic bag at the foot of the bed. The NA obtained peri-wash from the drawer and placed it on the plastic bag. Without changing gloves and/or performing hand hygiene, the NA provided peri-care. She removed the lid from the peri-wash, sprayed a wash cloth and cleansed Resident #14's perineal area. The NA obtained a second cloth, picked up the spray bottle containing peri-wash, with the same contaminated gloves, and cleansed the residents buttock's and anal area. Without drying the resident, the NA applied a clean brief and dressed Resident #14. The NA, interviewed immediately after the incontinence care observation, related she did not have a wash cloth to dry the resident. She also confirmed she should have used hand hygiene when transitioning from a dirty to clean area/task, and confirmed the potential for cross contamination. The NA also acknowledged the potential for infection from a moist environment. Review of the infection control line listing revealed Resident #14 was treated for [REDACTED]. The perineal care (peri-care) policy, reviewed on 05/28/15 at 2:00 p.m., noted to dry perineum thoroughly using a clean towel . c) An interview with the administrator on 05/28/15 at 3:00 p.m., and the Director of Nursing (DON) at 3:45 p.m., confirmed staff failed to provide care for Residents #5 and #14 in a manner which demonstrated effective infection control practices, creating a potential for cross contamination and the transmission and development of infection. d) Resident #71 During an observation, on 05/26/15 at 3:45 p.m., NA #74 was providing perineal care to Resident #71. Observation revealed a soiled brief on the floor. The NA completed the perineal care, fastened the resident's brief, reached in her pocket with the contaminated gloves, and pulled out a roll of bags. She washed her hands for a count of ten (10) seconds (CDC-P guidelines indicate hands should be scrubbed for at least 20 seconds.), turned off the faucet with her bare hands, and then dried her hands with a paper towel. An interview with Resident #71, on 05/28/15 at 9:25 a.m., revealed the resident had recurrent urinary tract infections. She related she could tell she had a UTI because of burning and sometimes itching. The resident said she sometimes had pressure or an urgency feeling. Review of the medical record revealed the resident was treated for [REDACTED]. A physician's progress note, dated 05/11/15, noted the use of an indwelling Foley catheter. The note indicated the resident complained of intermittent urinary pain, then hematuria on 05/07/15. A urinalysis and culture was obtained, and treatment with [MEDICATION NAME] (antibiotic therapy) initiated. e) Residents #70, #66, #64, #53, #52, #30, #48, #60, #54, and #38 An observation of the lunch meal, on 05/26/15, revealed staff passed trays and provided care to residents without sanitizing their hands between residents and/or as required when their hands became contaminated. 1. NA #31 passed a lunch tray to Resident #70. She did not sanitize her hands upon exiting the room. 2. NA #46 assisted Resident #66. The resident insisted the NA wash her dentures again, before she would place them in her mouth. The NA donned a glove on her right hand only. She rinsed the upper dentures, and returned them to the resident. The NA exited the room without sanitizing her hands. 3. NA #46 then pushed the fluid cart up the hallway and positioned it next to a clean linen cart. The NA entered the room of Resident #64, removed pillows and a book, and then exited the room without performing hand hygiene. 4. NA #46 next returned to the food cart, opened the door, scratched her head, and closed the door of the cart. The NA next obtained ice from the hydration cart for Resident #53. She exited the room without sanitizing her hands. 5. NA #46 returned to the food cart, obtained a tray and passed it to Resident #52 in an isolation room. She exited the isolation room without washing her hands. 6. NA #46 answered the call light for Resident #30. The resident requested ice. The NA went to the ice cart, located on another hallway; poured two (2) cups of ice without first sanitizing her hands, then served them to the resident. She exited the room without sanitizing her hands. 7. NA #46 walked down the hallway. She placed her fingers in her hair, and without sanitizing her hands, obtained a tray from the food cart. The NA served the tray to Resident #48. 8. NA #52 passed a tray to Resident #23. She did not sanitize her hands before she assisted Residents #64 and Resident #60 with positioning. These residents resided in different rooms. The NA did not sanitize her hands prior to, or upon exit, of either room. 9. NA #56 passed a meal tray to Resident #54 and exited the room without performing hand hygiene. The NA walked across the hallway and assisted another resident, then assisted Resident #38. She did not wash or sanitize her hands between or after assisting the residents. f) Review of the facility's hand hygiene policy revealed it required staff utilize hand hygiene . Before any direct contact with patient . after contact with patient's intact skin . when moving from contaminated body site to clean body site during patient care . after contact with inanimate objects in the immediate vicinity of the patient . before and after assisting with meals . after removing gloves . The hand hygiene procedure also required staff to use towel to turn off faucet upon completion of hand washing. g) Residents #46 and #52 During the initial tour, on 05/26/15 at 11:20 a.m., observations revealed signage was posted on the doors of Residents #46 and #52. It advised persons to not enter the room without speaking to the nurse. A bin with personal protective equipment (PPE) was placed outside the room. The bin contained gowns, gloves, and masks. An observation, on 05/27/15 at 8:46 a.m., revealed Registered Nurse (RN) #33 walked up to Resident #46's bed and drew the curtain. The RN utilized only gloves. There were specific precautions necessary in this room, related to an infection of clostridium difficile (C.diff), a multi-drug resistant organism (MDRO). The organism is transmitted via spores and can survive in the environment for six (6) or more months. In an interview with RN #33, at about 9:15 a.m. on 05/27/15, the nurse related he did not provide care to the resident, and therefore was not required to utilize PPE other than gloves. The RN also stated he did not know Resident #46 required precautions. He indicated they were required for the roommate, Resident #52. At that time, Ward Clerk #47 informed RN #33 that Resident #46 did require precaution for C.diff. During an interview with Resident #46, immediately following the interview with Ward Clerk #47, the resident stated RN #33 assessed his wounds. He confirmed RN #33 had not worn a gown. Review Resident #46's medical record, on 05/27/15 at 11:00 a.m., revealed the resident had loose stools on 05/24/15 and 05/26/15. A physician's orders [REDACTED]. h) The clostridium difficile (C.diff) policy was reviewed on 05/27/15 at 5:00 p.m. It required staff . maintain stringent hand washing . clean environment daily . paying special attention to doorknobs, light switches, bed rails, and over-bed tables. i) The line listing related to infections, reviewed on 05/27/15 at 1:15 p.m., revealed recurrent and/or on-going development of facility acquired urinary tract infections (UTIs) each month for the past six (6) months. 1. In December 2014, there were six (6). Three (3) were MDRO. 2. In January 2015, there were seventeen (17). Six (6) were MDRO 3. In February 2015, there were seven (7). Three (3) were MDRO 4. In March 2015, there were eight (8). One (1) was MDRO 5. In April 2015, there were nine (9). Four (4) were MDRO . Eight (8) residents had a change in level of consciousness and/or dysuria, fatigue, and greater than 100,000 colonies. 6. In May 2015. there were five (5). 7. Eschericia coli (e-coli) was the organism for twenty four (24) of fifty two (52) identified UTIs. Of the 24 e-coli infections, nine (9) were determined as extended spectrum beta lactimase (ESBL), a MDRO. i) An interview with the DON, assistant director of nursing (ADON) and nurse practitioner (NP), on 05/27/15 at 1:45 p.m., revealed a plan of action had not been developed for prevention of UTIs. He further acknowledged the facility had not notified the local health department about the continued development of facility acquired infections, nor completed a root cause analysis to identify how or why the infections were acquired. The DON said some education was completed related to perineal care; however, the DON was unable to provide evidence of the education/training. The DON also acknowledged staff had not utilized correct PPE measures when entering the room which required precautions. He said he had observed staff entering the room of Residents #46 and #52 without utilizing PPE. The DON also confirmed staff should have performed hand hygiene between residents.",2018-05-01
6173,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2015-05-28,520,F,1,0,25M511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical and facility record reviews, policy review, resident interview, staff interview, and review of the Centers for Disease Control and Prevention (CDC-P) guidelines for effective hand washing; the facility's quality assessment and assurance (QA&A) committee failed to identify and address a quality deficiency related to infection control. The QA&A committee should have, but did not recognize the facility's infection control issues represented a systems failure which required an action plan. Facility acquired urinary tract infections (including multi-drug resistant organisms), improper hand hygiene, and other breaches in infection control during the provision of resident care were not identified and addressed by the QA&A committee. Three (3) of eight (8) sample residents, plus eleven (11) additional residents identified during random opportunities for discovery, were affected; however, the practices had the potential to affect all facility residents. Resident identifiers: #5, #14, #71, #70, #66, #64, #53, #52, #30, #48, #60, #54, #38, and #46. Facility census: 72. Findings include: a) Resident #5 On 05/28/15 at 9:00 a.m., the resident said he had a [MEDICATION NAME] about six (6) to eight (8) months ago. He said he had recurrent urinary tract infections, stating he could tell when he had an infection because he had some pain. The resident also related the [MEDICATION NAME] sometimes leaked. Review of the medical record revealed physician's orders [REDACTED].#5 was treated for [REDACTED]. Upon request, Resident #5 allowed an observation of the [MEDICATION NAME] care on 05/27/15 at 9:43 a.m. Nursing Assistant (NA) #50 gathered supplies and placed the wash cloths on the back of the commode. She washed her hands, donned gloves, then placed the washcloths in the sink basin to wet them. After wringing the washcloths, by squeezing with her right hand and pushing the washcloths against the sink, the NA placed the cloths in a dry wash basin. She placed the basin on the over-the-bed table. When the NA was positioning the resident for care, the leg rests, which were at the foot of the bed, fell over. The NA picked up the leg rests, then continued with care without changing her gloves or performing hand hygiene. She placed a plastic bag on the bed, obtained paper towels, and a graduate. The NA placed the Foley drainage bag on the floor with no barrier beneath, then quickly picked it up. She drained the urine into the graduate, poured the urine into the commode, obtained a sprayer from the wall behind the commode, and rinsed out the graduate. The NA returned to the bedside and checked the [MEDICATION NAME] site. She stated the bag, and catheter were not due to be changed until the next day. The NA placed the washcloths in a bag, placed the wash basin in a different bag, then stored the basin on the floor of the resident's shower. The NA then removed her gloves and washed her hands; however, she turned off the faucet with her bare hand, contaminating her hand. A subsequent observation of [MEDICATION NAME] care, on 05/28/15 at 10:15 a.m., revealed a wash basin in the sink, and washcloths draped over the side of the sink. NA #50 placed a bag of supplies and an empty bag for garbage at the foot of the bed. During [MEDICATION NAME] care, the NA obtained a 4 x 4 individually wrapped gauze package from the bag. She moistened the gauze in the basin of water, which contained peri-wash, and cleansed the stoma and peri-wound area. The NA then washed across the stoma area again, with the same gauze. Licensed practical nurse (LPN) #28, assisted the NA. During the dressing change, the resident related NA #50 routinely provided his [MEDICATION NAME] care. After cleansing the wound, the NA secured the [MEDICATION NAME] appliance. During an interview immediately following, the NA related, she had read the procedure the night before to ensure she completed the procedure correctly. With further inquiry, the nursing assistant confirmed placing the washcloths on the back of the commode, on the side of the sink, and in an unsanitized sink provided a potential for cross contamination. b) Resident #14 During an incontinence care/perineal care observation, on 05/28/15 at 1:15 p.m., NA #64 (NA) donned gloves and filled a basin with water. She turned off the faucet with the gloved hands, placed washcloths in the wash basin, utilizing the same gloves. She continued the process, placing a plastic bag at the foot of the bed. The NA obtained peri-wash from the drawer and placed it on the plastic bag. Without changing gloves and/or performing hand hygiene, the NA provided peri-care. She removed the lid from the peri-wash, sprayed a wash cloth and cleansed Resident #14's perineal area. The NA obtained a second cloth, picked up the spray bottle containing peri-wash, with the same contaminated gloves, and cleansed the residents buttock's and anal area. Without drying the resident, the NA applied a clean brief and dressed Resident #14. The NA, interviewed immediately after the incontinence care observation, related she did not have a wash cloth to dry the resident. She also confirmed she should have used hand hygiene when transitioning from a dirty to clean area/task, and confirmed the potential for cross contamination. The NA also acknowledged the potential for infection from a moist environment. Review of the infection control line listing revealed Resident #14 was treated for [REDACTED]. The perineal care (peri-care) policy, reviewed on 05/28/15 at 2:00 p.m., noted to dry perineum thoroughly using a clean towel . c) An interview with the administrator on 05/28/15 at 3:00 p.m., and the Director of Nursing (DON) at 3:45 p.m., confirmed staff failed to provide care for Residents #5 and #14 in a manner which demonstrated effective infection control practices, creating a potential for cross contamination and the transmission and development of infection. d) Resident #71 During an observation, on 05/26/15 at 3:45 p.m., NA #74 was providing perineal care to Resident #71. Observation revealed a soiled brief on the floor. The NA completed the perineal care, fastened the resident's brief, reached in her pocket with the contaminated gloves, and pulled out a roll of bags. She washed her hands for a count of ten (10) seconds (CDC-P guidelines indicate hands should be scrubbed for at least 20 seconds.), turned off the faucet with her bare hands, then dried her hands with a paper towel. An interview with Resident #71, on 05/28/15 at 9:25 a.m., revealed the resident had recurrent urinary tract infections. She related she could tell she had a UTI because of burning and sometimes itching. The resident said she sometimes had pressure or an urgency feeling. Review of the medical record revealed the resident was treated for [REDACTED]. A physician's progress note, dated 05/11/15, noted the use of an indwelling Foley catheter. The note indicated the resident complained of intermittent urinary pain, then hematuria on 05/07/15. A urinalysis and culture was obtained, and treatment with [MEDICATION NAME] (antibiotic therapy) initiated. e) Residents #70, #66, #64, #53, #52, #30, #48, #60, #54, and #38 An observation of the lunch meal, on 05/26/15, revealed staff passed trays and provided care to residents without sanitizing their hands between residents and/or as required when their hands became contaminated. 1. NA #31 passed a lunch tray to Resident #70. She did not sanitize her hands upon exiting the room. 2. NA #46 assisted Resident #66. The resident insisted the NA wash her dentures again, before she would place them in her mouth. The NA donned a glove on her right hand only. She rinsed the upper dentures, and returned them to the resident. The NA exited the room without sanitizing her hands. 3. NA #46 then pushed the fluid cart up the hallway and positioned it next to a clean linen cart. The NA entered the room of Resident #64, removed pillows and a book, then exited the room without performing hand hygiene. 4. NA #46 next returned to the food cart, opened the door, scratched her head, and closed the door of the cart. The NA next obtained ice from the hydration cart for Resident #53. She exited the room without sanitizing her hands. 5. NA #46 returned to the food cart, obtained a tray and passed it to Resident #52 in an isolation room. She exited the isolation room without washing her hands. 6. NA #46 answered the call light for Resident #30. The resident requested ice. The NA went to the ice cart, located on another hallway, poured two (2) cups of ice without first sanitizing her hands, then served them to the resident. She exited the room without sanitizing her hands. 7. NA #46 walked down the hallway. She placed her fingers in her hair, and without sanitizing her hands, obtained a tray from the food cart. The NA served the tray to Resident #48. 8. NA #52 passed a tray to Resident #23. She did not sanitize her hands before she assisted Residents #64 and Resident #60 with positioning. These residents resided in different rooms. The NA did not sanitize her hands prior to, or upon exit, of either room. 9. NA #56 passed a meal tray to Resident #54 and exited the room without performing hand hygiene. The NA walked across the hallway and assisted another resident, then assisted Resident #38. She did not wash or sanitize her hands between or after assisting the residents. f) Review of the facility's hand hygiene policy revealed it required staff utilize hand hygiene . Before any direct contact with patient .after contact with patient's intact skin . when moving from contaminated body site to clean body site during patient care . after contact with inanimate objects in the immediate vicinity of the patient . before and after assisting with meals . after removing gloves . The hand hygiene procedure also required staff to use towel to turn off faucet upon completion of hand washing. g) Residents #46 and #52 During the initial tour, on 05/26/15 at 11:20 a.m., observation revealed signage was posted on the doors of Residents #46 and #52. It advised persons not to enter the room without speaking to the nurse. A bin with personal protective equipment (PPE) was placed outside the room. The bin contained gowns, gloves, and masks. Observation, on 05/27/15 at 8:46 a.m., revealed Registered Nurse (RN) #33 walked up to Resident #46's bed and drew the curtain. The RN utilized only gloves. There were specific precautions necessary in this room, related to an infection of [MEDICAL CONDITION] (C.diff), a multi-drug resistant organism (MDRO). The organism is transmitted via spores and can survive in the environment for six (6) or more months. In an interview with RN #33, at about 9:15 a.m. on 05/27/15, the nurse related he did not provide care to the resident, and therefore, was not required to utilize PPE other than gloves. The RN also stated he did not know Resident #46 required precautions. He indicated they were required for the roommate, Resident #52. At that time, Ward Clerk #47 informed RN #33 that Resident #46 did require precaution for C.diff. During an interview with Resident #46, immediately following the interview with Ward Clerk #47, the resident stated RN #33 assessed his wounds. He confirmed RN #33 had not worn a gown. Review Resident #46's medical record, on 05/27/15 at 11:00 a.m., revealed the resident had loose stools on 05/24/15 and 05/26/15. A physician's orders [REDACTED]. h) The [MEDICAL CONDITION] (C.diff) policy, was reviewed on 05/27/15 at 5:00 p.m. It required staff . maintain stringent hand washing . clean environment daily . paying special attention to doorknobs, light switches, bed rails, and over-bed tables. i) The line listing related to infections, reviewed on 05/27/15 at 1:15 p.m., revealed recurrent and/or on-going development of facility acquired urinary tract infections (UTIs) each month for the past six (6) months. 1. In December 2014, there were six (6). Three (3) were MDRO. 2. In January 2015, there were seventeen (17). Six (6) were MDRO 3. In February 2015, there were seven (7) . Three (3) were MDRO 4. In March 2015, there were eight (8). One (1) was MDRO 5. In April 2015, there were nine (9). Four (4) were MDRO Eight (8) residents had a change in level of consciousness and/or dysuria, fatigue, and greater than 100,000 colonies. 6. In May 2015. there were five (5). 7. Eschericia coli (e-coli) was the organism for twenty four (24) of fifty two (52) identified UTIs. Of the 24 e-coli infections, nine (9) were determined as extended spectrum beta lactimase (ESBL), a MDRO. j) An interview with the quality assessment and assurance (QA&A) committee members, the DON, assistant director of nursing (ADON) and nurse practitioner (NP), on 05/27/15 at 1:45 p.m., revealed the QA&A committee met monthly. Upon inquiry, the DON said UTIs had not been addressed through QA&A. He confirmed the QA&A committee had not developed a plan of action to address the UTIs and/or the prevention of UTIs. The DON acknowledged the facility had not notified the local health department about the continued development of facility acquired infections, had not completed a root cause analysis to identify how or why the infections were acquired, and had not implemented an action plan related to the facility acquired infections. .",2018-05-01
6852,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2014-02-14,160,D,0,1,U18411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personal funds review and staff interview, the facility failed to ensure one (1) of two (2) residents reviewed had personal funds conveyed, and a final accounting of those funds sent to the individual or probate jurisdiction administering the resident's estate, within 30 days of the resident's death. The facility disbursed funds from the deceased resident's account to a funeral home instead of to the resident's estate. In addition, the facility did not return a social security check received for the resident after his death to the social security administration. Resident identifier: #59. Facility census: 70. Findings include: a) Resident #59 A review of the personal funds, on [DATE] at 4:00 p.m., revealed Resident #58 expired on [DATE]. The facility wrote a check for $250.08 to the funeral home on [DATE]. The administrator (Employee #80) confirmed the facility had sent the final accounting of resident's funds which totaled $250.08 to a funeral home instead of to the resident's estate. The administrator said he knew he had not acted appropriately when he sent the resident's money to a funeral home instead of to the resident's estate. He indicated the resident's family did not have the financial ability to apply to become executor of his estate; therefore, he elected to send the money in the resident's trust account to the funeral home to assist with burial expenses. On [DATE] at 4:27 p.m., the administrator (Employee #80) and the business office manager (Employee #82) said a social security check was deposited into the resident's facility trust account on [DATE]. The check remained in the resident's account on [DATE]. The business office manager said she had a conference call with her company representative on [DATE]. During that call Employee #82 had to look at the facility's closed resident trust accounts. At that point she discovered the social security check for Resident #58 remained in the resident's closed account. The office manager said she thought the money would automatically revert back to social security, so she never went into the resident's account after it closed to make sure this check had been returned. She said her company would assist her in getting this money returned to social security, but that process might take a couple days.",2017-11-01
6853,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2014-02-14,242,D,0,1,U18411,"Based on a random observation, resident interview, staff interview, and review of the resident's meal preference card, the facility failed to ensure one (1) of seventy (70) residents was afforded the right to make a choice about aspects of life in the facility which were significant to her. Resident #14's known food preferences were not honored for the breakfast meal. Resident identifier: #14 Facility census: 70.Findings include: a) Resident #14 During a random observation on 02/14/14 at 9:30 a.m., Resident #14 was observed at breakfast. She stated she was upset about not getting her usual breakfast of two (2) fried eggs and toast. The resident stated she had a breakfast food preference which was usually honored by the dietary department. She said she could not understand why she had not received her breakfast of choice because it was noted as a like on her tray slip. The resident rang her call light. When Employee #56, a registered nurse (RN) answered, the resident told her she had been waiting for her breakfast for over 30 minutes. She further stated she did not like the meal she was served and stated, Now I want eggs and toast. Employee #56 stated the resident had requested her normal breakfast of choice over thirty (30) minutes prior to this observation. She said dietary had been notified prior to the observation at 9:30 a.m. Interviews with Employee #23, nurse aide (NA), Employee #35 (NA), and Employee #56 (RN), on 02/14/14 at 9:50 a.m., revealed they had all asked the kitchen for Resident #13's usual breakfast. They said dietary staff informed them they did not have any eggs and offered dry cereal instead, which the resident refused. At 10:00 a.m. on 02/14/14, the situation was brought to the attention of Employee #80, (administrator). He said I'll take care of it. On 02/14/14 at 10:48 a.m., the chef manager (Employee #42) was asked if food preferences were documented. The chef manager provided a list of Resident #14's food preferences. It indicated the resident preferred bacon and two (2) fried eggs for breakfast. The resident's preferences were also located on a dry erase board which dietary staff utilized while serving meals. The chef manager further explained they did not have any eggs to fix that morning, because the food truck had not yet arrived. Employee #42 stated he had to go to a local store to purchase some eggs. Resident #14 received her eggs at 10:15 a.m., two (2) hours after she requested her usual breakfast.",2017-11-01
6854,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2014-02-14,246,D,0,1,U18411,"Based on observations and staff interview, the facility failed to ensure reasonable accommodations of need for one (1) resident identified while observing thirty (30) rooms during Stage 1 of the survey. The resident's bathroom/shower area call light was not in reach should it be needed in an emergency. Resident Identifier: #155. Facility Census: 70. Findings Include: a) Resident #155 Observation of Resident #155's call light in her bathroom/shower area, at 12:57 p.m. on 02/11/14, revealed the call light in the bathroom/shower area did not have a cord attached to the call light button. The resident would have not been able to activate the call light system should she need to do so while in her bathroom. On 02/11/3 at 2:30 p.m., Employee #80, Nursing Home Administrator (NHA), was notified Resident #155's call system in the bathroom/shower area did not have a cord attached for the resident to reach and use if needed. The Administrator confirmed there was not a cord attached. He agreed a cord was needed so the resident could access the call system if necessary.",2017-11-01
6855,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2014-02-14,253,E,0,1,U18411,"Based on observations and staff interview, the facility failed to provide maintenance and housekeeping services necessary to maintain a comfortable and sanitary interior for four (4) of twenty-seven (27) rooms/bathrooms observed during stage 1 of the survey. Rooms 305, 306, and 402 had walls in the bathroom areas which were not in good repair. Room 312 had a liquid substance spilled on the wall which was not cleaned for at least 48 hours. This practice had the potential to affect more than an isolated number of residents. Facility Census: 70. Findings Include: a) Rooms 305, 306 and 402 -- Room 305 was observed at 10:48 a.m., on 02/11/14. This observation revealed the wall in the bath room was scratched, had missing paint, and was in poor repair. -- Room 306 was observed at 10:10 a.m., on 02/11/14. The bathroom had screw holes in the wall, scratched walls with missing paint, and was in poor repair. -- Room 402 was observed at 8:00 a.m., on 02/11/14. The bathroom had torn drywall which was also scratched and in poor repair. Employee #80, the nursing home administrator (NHA), and Employee #81, the Maintenance Supervisor, toured the facility at 3:30 p.m. on 02/12/14. They confirmed the bathroom walls in rooms 305, 306 and 402 were not in good repair. They confirmed the screw holes and scratches needed repaired. b) Room 312 Observations of Room 312 were made at 2:35 p.m. on 02/10/14. This observation revealed a section of the wall near the sink was discolored as though a liquid substance was spilled on the wall. Additional observations of Room 312 were also made at 3:00 p.m. on 02/12/14. This observation revealed the substance remained on the wall. On 02/12/14 at 3:35 p.m., Employee #80 confirmed there was a substance spilled on the wall of room 312. He stated he would have to tell housekeeping to clean the wall. He also confirmed it did not appear to be a recent spill.",2017-11-01
6856,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2014-02-14,280,D,0,1,U18411,"Based on record review, staff interview, and resident observations, the facility failed to revise one (1) of seventeen (17) resident's care plans reviewed during Stage 2 of the survey. The care plan for a fall intervention was not revised when the plan was determined to be an inappropriate intervention for the resident. Resident Identifier: #84. Facility Census: 70. Findings Include: a) Resident #84 Review of Resident #84's care plan, at 1:35 p.m. on 02/13/14, revealed a focus of, (Resident #84) is at risk for falls d/t (due to) unsteady gait, h/o (history of) falls, h/o dizziness, cognitive loss, lack of safety awareness, wandering The care plan listed multiple interventions related to this focus, one of which was, Room to be rearranged to promote safety. Bed to be turned against wall to increase access to BSC (Bed Side Commode). Resident #84 was observed at 1:41 p.m. on 02/13/14. Resident #84 was resting in bed at the time of the observation. The bed was observed to not be against the wall. Employee #62, Director of Nursing, Registered Nurse, (DON) (RN), was interviewed at 1:45 p.m. on 02/13/14. She confirmed Resident #84's bed was not currently turned against the wall. She stated they had discussed doing this and had added it to the care plan, but when they went into her room to rearrange the bed, the resident did not want her bed moved. The DON confirmed the intervention should have been removed from the care plan.",2017-11-01
6857,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2014-02-14,323,E,0,1,U18411,"Based on water temperature measurements, observations, record review, review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), staff interview, and policy review, the facility failed to ensure the resident environment was as free of accident hazards as possible. The temperature of the water at a resident's sink was too hot. Further investigation revealed excessive hot water temperatures was an on-going problem. In addition, the facility failed to ensure medications were secured in safe areas where cognitively impaired residents would be unable to gain access to them. These practices had the potential to affect more than an isolated number of residents. Resident Identifier: #84. Facility Census: 70. Findings Include: a) Water Temperatures During Stage 1 of the survey, at 1:56 p.m. on 02/10/14, the water temperature in resident room 304 was tested by touch. The hot water appeared to be too warm to touch, as the surveyor was not able to keep her hand submerged in the water for greater than one (1) second. At 2:05 p.m. on 02/10/14, a water temperature measurement was obtained at the sink in room 304 by Employee #81, the maintenance supervisor, using a facility thermometer. The temperature of the water was 121 degrees Fahrenheit (F). As the water continued to run for a few minutes, the temperature went from 121 degrees F to 110 degrees F. Employee #81 was interviewed regarding the drastic decrease in the water temperature in a matter of minutes. He stated he had been having problems getting the water temperatures regulated for the past couple of weeks. He stated when the boiler emptied the water into the hot water tanks, the water got too hot. The Maintenance Supervisor stated there was no way of keeping that water from going to the resident rooms. Employee #81 stated he had the mixing valve set to 110 degrees Fahrenheit, but when the water emptied from the boiler into the tank, the temperature would spike for a few minutes until the hot water tanks emptied out a little bit. Employee #81 stated he checked the water temperatures weekly and made the needed adjustments to the water to ensure the water stayed at a safe temperature. The facility water temperature logs were reviewed for the previous six (6) months. From November 2013 until February 2014, the temperatures recorded in the logs indicated water temperatures were: -- 11/05/13: Room (101) 121.3 degrees (F), Room (104) 122.4 degrees (F), Room (202) 126.1 degrees (F), Room (206) 124.8 degrees, Room 300 126.3 degrees, Room (305) 126.1 degrees (F), Room (401) 124.1 degrees (F), Room (404) 126.6 degrees (F). -- 11/11/13: Room (102) 121.6 degrees, Room (104) 122.4 degrees (F), Room (203) 121.8 degrees (F), Room (205) 124.8 degrees (F), Room (305) 118.8 degrees (F), Room (306) 120.2 degrees (F), Room (400) 124.4 degrees (F), Room (404) 121.8 degrees (F). -- 11/19/13 Room (101) 118.6 degrees (F), Room (102) 119.0 degrees (F), Room (204) 119.6 degrees (F), Room (205) 117.9 degrees, Room (302) 119.1 degrees (F), Room (304) 118.8 degrees (F), Room (400) 120.2 degrees (F), Room (404) 120.6 degrees (F). -- 11/26/13 Room (101) 112.6 degrees, Room (104) 111.8 degrees, Room (204) 111.9 degrees, Room (206) 110.9 degrees, Room (304) 113.1 degrees, Room (305) 112.8 degrees (F), Room (400) 111.1 degrees (F), Room (406) 112.7 degrees. -- 12/05/14 Room (102) 104.5 degrees (F), Room (104) 105.1 degrees (F), Room (204) 105.1 degrees (F), Room (205) 105.5 degrees (F), Room (302) 104.0 degrees (F), Room (306) 103.6 degrees (F), Room (400) 119.1 degrees (F), Room (404) 118.7 degrees (F). -- 12/12/13 Room (106) 118.2 degrees (F), Room (107) 117.6 degrees (F), Room (203) 122.2 degrees (F), Room 207 119.1 degrees, Room 310 118.0 degrees, Room (311) 118.6 degrees (F), Room (400) 101.2 degrees (F), Room (404)102.8 degrees F. -- 12/19/13 Room (102) 111.7 degrees (F), Room (103) 111.9 degrees (F), Room (205) 121.8 degrees (F), Room (208) 123.3 degrees (F), Room (300) 113.9 degrees (F), Room (306) 114.1 degrees (F), Room (402) 113.2 degrees (F), Room (409) 118.2 degrees (F). -- 12/24/13 Room 104 124.7 degrees, Room 106 124.3 degrees, Room (207) 123.3 degrees (F), Room 209 124.9 degrees, Room 300 118.4 degrees, Room (305) 123.2 degrees (F), Room (400) 123.6 degrees (F), Room (404) 123.7 degrees (F). -- 01/02/14 Room (101) 121.1 degrees (F), Room (104) 120.3 degrees (F), Room (202) 129.4 degrees (F), Room (206) 128.4 degrees (F), Room (303) 127.6 degrees (F), Room (305)127.9 degrees (F), Room (401) 120.4 degrees (F), Room (405) 121.7 degrees (F). -- 01/09/14 Room (102) 122.7 degrees (F), Room (104) 119.6 degrees, Room (204) 132.8 degrees, Room (206) 125.2 degrees, Room (310) 125.1 degrees, Room (312 )126.1 degrees (F), Room (402) 118.0 degrees, Room (404) 119.1 degrees (F). -- 01/17/14 Room (102) 115.2 degrees, Room (106) 114.9 degrees, Room (204) 112.6 degrees, Room (208) 112.8 degrees, Room 300 112.9 degrees, Room (306) 112.7 degrees, Room (402) 109.2 degrees, Room (404) 108.7 degrees. -- 01/24/14 Room (106) 114.7 degrees, Room (111) 115.1 degrees, Room (202) 114.7 degrees, Room (206) 116.1 degrees, Room (304) 119.1 degrees, Room (306) 120.4 degrees, Room (402) 117.9 degrees, Room (405) 119.9 degrees. -- 01/30/14 Room (102) 127.9 degrees Room (104) 126.4 degrees, Room (201) 128.1 degrees, Room (204) 126.6 degrees, Room (303) 129.7 degrees, Room (306) 128.1 degrees, Room (403) 122.2 degrees, Room (404) 125.1 degrees -- 01/30/14 Room (102) 127.9 degrees, Room (104) 126.4 degrees, Room (201) 128.1 degrees, Room (204) 126.6 degrees, Room (303) 129.7 degrees, Room (306) 128.1 degrees, Room (403) 122.2 degrees,Room (404) 125.1 degrees. -- 02/05/14 Room (102) 104.9 degrees (F), Room (105) 108.7 degrees (F), Room (200) 110.7 degrees (F), Room (206) 109.4 degrees, Room (302) 108.5 degrees, Room (306) 109.1 degrees (F), Room (400) 109.4 degrees (F), Room (404) 107.4 degrees (F). During the period of 11/15/13 through 02/05/14, the facility's hot water temperatures were measured and recorded fifteen (15) times. The temperatures recorded in the logs indicated water temperatures were greater than 110 degrees F, in one (1) or more rooms, on every day the temperatures were measured. In addition, the water temperature in one (1) or more resident rooms was at or above 120 degrees (F) during twelve (12) of the evaluations by facility staff. The exceptions were the weeks of 11/26/13, 12/05/13, and 01/17/14. According to Table 1 in the Guidance to Surveyors related to comfortable/safe water temperatures, found in Appendix PP of the CMS State Operations Manual, a third (3rd) degree burn can occur at 120 degrees with exposure of five (5) minutes. Burns can occur even at water temperatures below that level depending on the exposed individual's condition and the length of exposure. An additional interview with Employee #81 was conducted on 02/11/14 at 8:30 a.m. He stated he did not want the water temperatures to be above 110 degrees. Employee #81 stated they monitor the water temperatures by taking weekly temperatures and adjusting the mixing valve temperatures accordingly. He stated, you have to be careful because a degree or two either way can cause the water to be too hot or too cold. Employee #81 stated he checked the water temperatures after the adjustments, but did not keep any records other than the weekly temperature log. The nursing home administrator (NHA) was interviewed at 10:00 a.m. on 02/11/14. He stated Employee #81 needed to keep better records of the water temperatures taken after he made adjustments to the mixing valve. The NHA stated he believed the maintenance supervisor was doing them, but was just not keeping a record of them. The NHA stated he did not review the water temperature logs and had no idea of any problems related to the water temperatures being too high. The NHA stated he agreed that temperatures at or above 110 degrees were too high. He stated they needed to keep the temperatures as close to 110 degrees as possible. b) Resident #84 During Stage 1 of the survey, room observations were conducted of Resident #84's room at 10:12 a.m. on 02/11/14. A bottle of Pepto Bismol was observed on Resident #84's night stand. The director of nursing (DON) was interviewed at 10:15 a.m. on 02/11/14. She stated Resident #84 should not have the bottle of Pepto Bismol in her room. She promptly removed the medication from Resident #84's room and stated the resident's family must have brought the medication in to Resident #84. The facility's policy titled Medications: Self Administration was reviewed at 2:00 p.m. on 02/12/14. This review revealed the following statements regarding the self administration of medications: 1. When a patient requests medication self administration, complete the Self-Administration of Medications Evaluation , 4. Secure medications in a locked drawer at patient's bedside. Assure that patient and nursing both have a key . An additional interview with the DON, at 2:30 p.m. on 02/12/14, revealed the facility had no knowledge Resident #84 had Pepto Bismol in her room. She stated the facility did not complete a Self Administration of Medications Evaluation because they had no knowledge the resident had the medication. The DON confirmed the medication was brought to the resident by a family member. She stated Resident #84 was not considered safe to self-administer medications.",2017-11-01
6858,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2014-02-14,371,F,0,1,U18411,"Based on observations in the dietary department and staff interview, it was found the facility failed to maintain food items and equipment in a manner which ensured proper sanitation techniques were employed. Food items were found open, but not dated when they had been opened. Additionally, equipment was found in need of cleaning. These findings had the potential to affect all residents who consumed foods by oral means, as all the foods were prepared and served from this central location. Census: 70. Findings include: a) During the initial tour of the dietary department, on 02/10/14 at 11:25 a.m., with Employee #34, the Environmental Services Supervisor, the following issues were discovered and confirmed: 1) A container of thickener on a shelf with spices was not labeled or dated when it was taken from original container and opened for use. 2) The drip pan under the stove top had food debris. 3) Grease was observed behind the range on the wall. b) A glass pitcher of milk in the reach-in refrigerator was not covered. c) A tray in the reach-in refrigerator contained individual cups of juice which were not labeled with the date the juice was poured.",2017-11-01
6859,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2014-02-14,514,D,0,1,U18411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure medical records were maintained in a manner in which the information was recorded accurately. A nursing note, documented the day after a resident expired, was not identified as a late entry. This practice was evident for one (1) of fifty-seven (57) medical records reviewed. Census: 70. Findings include: a) Resident #66 Review of the medical record for Resident #66 revealed nursing staff documented an entry dated [DATE] at 14:18 (2:18 p.m.). This note indicated the resident was found unresponsive. The resident's wife and 911 were contacted. The paramedics came and transported the resident to a local hospital, where he expired a short time later . On [DATE], another nursing entry was listed at 15:05 (3:05 p.m.). It contained additional details regarding what interventions were implemented when the resident was found unresponsive. This note was not identified as a late entry. Discussion with the director of nursing (DON), Employee #61, and Employee #98 (the medical director), at 10:45 a.m. on [DATE], revealed the note on [DATE] should have been recorded as a late entry. The DON confirmed the note dated [DATE] was linked to the note of [DATE], but was not shown to be a late entry.",2017-11-01
6860,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2014-02-14,520,E,0,1,U18411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on water temperature measurements, observations, record review, review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), and staff interview, the Quality Assurance and Assessment (QAA) Committee failed to identify and correct a quality deficiency related to water temperatures. The facility failed to maintain hot water temperatures within a safe range. This practice had the potential to affect more than an isolated number of residents. Facility Census: 70. Findings Include: a) Water Temperatures During Stage 1 of the survey, at 1:56 p.m. on 02/10/14, the water temperature in resident room [ROOM NUMBER] was tested by touch. The hot water appeared to be too warm to touch, as the surveyor was not able to keep her hand submerged in the water for greater than one (1) second. At 2:05 p.m. on 02/10/14, a water temperature measurement was obtained at the sink in room [ROOM NUMBER] by Employee #81, the maintenance supervisor, using a facility thermometer. The temperature of the water was 121 degrees Fahrenheit (F). As the water continued to run for a few minutes, the temperature went from 121 degrees F to 110 degrees F. Employee #81 was interviewed regarding the drastic decrease in the water temperature in a matter of minutes. He stated he had been having problems getting the water temperatures regulated for the past couple of weeks. He stated when the boiler emptied the water into the hot water tanks, the water got too hot. The Maintenance Supervisor stated there was no way of keeping that water from going to the resident rooms. Employee #81 stated he had the mixing valve set to 110 degrees Fahrenheit, but when the water emptied from the boiler into the tank, the temperature would spike for a few minutes until the hot water tanks emptied out a little bit. Employee #81 stated he checked the water temperatures weekly and made the needed adjustments to the water to ensure the water stayed at a safe temperature. The facility water temperature logs were reviewed for the previous six (6) months. From November 2013 until February 2014, the temperatures recorded in the logs indicated water temperatures were: -- 11/05/13: Room (101) 121.3 degrees (F), Room (104) 122.4 degrees (F), Room (202) 126.1 degrees (F), Room (206) 124.8 degrees, room [ROOM NUMBER] 126.3 degrees, Room (305) 126.1 degrees (F), Room (401) 124.1 degrees (F), Room (404) 126.6 degrees (F). -- 11/11/13: Room (102) 121.6 degrees, Room (104) 122.4 degrees (F), Room (203) 121.8 degrees (F), Room (205) 124.8 degrees (F), Room (305) 118.8 degrees (F), Room (306) 120.2 degrees (F), Room (400) 124.4 degrees (F), Room (404) 121.8 degrees (F). -- 11/19/13 Room (101) 118.6 degrees (F), Room (102) 119.0 degrees (F), Room (204) 119.6 degrees (F), Room (205) 117.9 degrees, Room (302) 119.1 degrees (F), Room (304) 118.8 degrees (F), Room (400) 120.2 degrees (F), Room (404) 120.6 degrees (F). -- 11/26/13 Room (101) 112.6 degrees, Room (104) 111.8 degrees, Room (204) 111.9 degrees, Room (206) 110.9 degrees, Room (304) 113.1 degrees, Room (305) 112.8 degrees (F), Room (400) 111.1 degrees (F), Room (406) 112.7 degrees. -- 12/05/14 Room (102) 104.5 degrees (F), Room (104) 105.1 degrees (F), Room (204) 105.1 degrees (F), Room (205) 105.5 degrees (F), Room (302) 104.0 degrees (F), Room (306) 103.6 degrees (F), Room (400) 119.1 degrees (F), Room (404) 118.7 degrees (F). -- 12/12/13 Room (106) 118.2 degrees (F), Room (107) 117.6 degrees (F), Room (203) 122.2 degrees (F), room [ROOM NUMBER] 119.1 degrees, room [ROOM NUMBER] 118.0 degrees, Room (311) 118.6 degrees (F), Room (400) 101.2 degrees (F), Room (404)102.8 degrees F. -- 12/19/13 Room (102) 111.7 degrees (F), Room (103) 111.9 degrees (F), Room (205) 121.8 degrees (F), Room (208) 123.3 degrees (F), Room (300) 113.9 degrees (F), Room (306) 114.1 degrees (F), Room (402) 113.2 degrees (F), Room (409) 118.2 degrees (F). -- 12/24/13 room [ROOM NUMBER] 124.7 degrees, room [ROOM NUMBER] 124.3 degrees, Room (207) 123.3 degrees (F), room [ROOM NUMBER] 124.9 degrees, room [ROOM NUMBER] 118.4 degrees, Room (305) 123.2 degrees (F), Room (400) 123.6 degrees (F), Room (404) 123.7 degrees (F). -- 01/02/14 Room (101) 121.1 degrees (F), Room (104) 120.3 degrees (F), Room (202) 129.4 degrees (F), Room (206) 128.4 degrees (F), Room (303) 127.6 degrees (F), Room (305)127.9 degrees (F), Room (401) 120.4 degrees (F), Room (405) 121.7 degrees (F). -- 01/09/14 Room (102) 122.7 degrees (F), Room (104) 119.6 degrees, Room (204) 132.8 degrees, Room (206) 125.2 degrees, Room (310) 125.1 degrees, Room (312 )126.1 degrees (F), Room (402) 118.0 degrees, Room (404) 119.1 degrees (F). -- 01/17/14 Room (102) 115.2 degrees, Room (106) 114.9 degrees, Room (204) 112.6 degrees, Room (208) 112.8 degrees, room [ROOM NUMBER] 112.9 degrees, Room (306) 112.7 degrees, Room (402) 109.2 degrees, Room (404) 108.7 degrees. -- 01/24/14 Room (106) 114.7 degrees, Room (111) 115.1 degrees, Room (202) 114.7 degrees, Room (206) 116.1 degrees, Room (304) 119.1 degrees, Room (306) 120.4 degrees, Room (402) 117.9 degrees, Room (405) 119.9 degrees. -- 01/30/14 Room (102) 127.9 degrees Room (104) 126.4 degrees, Room (201) 128.1 degrees, Room (204) 126.6 degrees, Room (303) 129.7 degrees, Room (306) 128.1 degrees, Room (403) 122.2 degrees, Room (404) 125.1 degrees -- 01/30/14 Room (102) 127.9 degrees, Room (104) 126.4 degrees, Room (201) 128.1 degrees, Room (204) 126.6 degrees, Room (303) 129.7 degrees, Room (306) 128.1 degrees, Room (403) 122.2 degrees,Room (404) 125.1 degrees. -- 02/05/14 Room (102) 104.9 degrees (F), Room (105) 108.7 degrees (F), Room (200) 110.7 degrees (F), Room (206) 109.4 degrees, Room (302) 108.5 degrees, Room (306) 109.1 degrees (F), Room (400) 109.4 degrees (F), Room (404) 107.4 degrees (F). During the period of 11/15/13 through 02/05/14, the facility's hot water temperatures were measured and recorded fifteen (15) times. The temperatures recorded in the logs indicated water temperatures were greater than 110 degrees F, in one (1) or more rooms, on every day the temperatures were measured. In addition, the water temperature in one (1) or more resident rooms was at or above 120 degrees (F) during twelve (12) of the evaluations by facility staff. The exceptions were the weeks of 11/26/13, 12/05/13, and 01/17/14. According to Table 1 in the Guidance to Surveyors related to comfortable/safe water temperatures, found in Appendix PP of the CMS State Operations Manual, a third (3rd) degree burn can occur at 120 degrees with exposure of five (5) minutes.[MEDICAL CONDITION] occur even at water temperatures below that level depending on the exposed individual's condition and the length of exposure. An additional interview with Employee #81 was conducted on 02/11/14 at 8:30 a.m. He stated he did not want the water temperatures to be above 110 degrees. Employee #81 stated they monitor the water temperatures by taking weekly temperatures and adjusting the mixing valve temperatures accordingly. He stated, you have to be careful because a degree or two either way can cause the water to be too hot or too cold. Employee #81 stated he checked the water temperatures after the adjustments, but did not keep any records other than the weekly temperature log. The nursing home administrator (NHA) was interviewed at 10:00 a.m. on 02/11/14. He stated Employee #81 needed to keep better records of the water temperatures taken after he made adjustments to the mixing valve. The NHA stated he believed the maintenance supervisor was doing them, but was just not keeping a record of them. The NHA stated he did not review the water temperature logs and had no idea of any problems related to the water temperatures being too high. The NHA stated he agreed that temperatures at or above 110 degrees were too high. He stated they needed to keep the temperatures as close to 110 degrees as possible. The NHA was again interviewed at 3:30 p.m. on 02/13/14 regarding the QAA committee. He reported water temperatures were something which was not discussed at the monthly QAA committee meetings. He reported Employee #81, the maintenance supervisor, participated in the QAA meetings, but he had never mentioned the water temperatures running too high. The NHA confirmed water temperatures being too high was something Employee #81 should have discussed at the monthly QAA meetings. He commented during the meetings the committee members were asked if there was anything else to report. The NHA said Employee #81 should have brought up the consistently high water temperatures at that time. The NHA stated the members of the committee would have been able to offer him support and a plan would have been developed to address the high water temperatures to correct the quality deficiency.",2017-11-01
6937,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2017-05-30,242,D,1,0,NRE111,"Based on staff interview and resident interview, the facility failed to ensure one (1) of one (1) residents made choices about aspects of their life significant to them. Resident #32 wanted to have diet cola to drink. The facility did not provide any type of diet cola for the resident at meals. Resident identifier: #32. Facility census: 74. Findings include: a) Resident #32 On 05/24/17 at 1:00 p.m., during an interview with Resident #32 he commented he would like to have a diet cola to drink with his meals. He said the facility did not have any type of soda except ginger ale. He said he did not like to drink ginger ale. He said the facility use to have diet cola but had not had it available for a long time. On 05/25/17 at 10:00 a.m., during an interview with the director of nursing (DON), the DON stated he was aware of the resident's desire to have diet soda. He commented the facility did not provide diet soda. He mentioned they did offer ginger ale to the residents. At 10:15 a.m. on 05/25/17, Dining Service Director (DCD) #23 said the facility did not order soda of any kind. He said when the facility purchased soda before the staff would end up drinking the soda. At 10:30 a.m. on 05/25/17, Resident #32 said he use to get two (2) small cans of diet soda a day and that was what he liked. He said it would be nice to get this again and he would be okay with just getting two (2) cans. On 05/25/17 at 11:00 a.m., the administrator said he had provided soda before but due to nutritional concerns and cost he could not make this a standard choice for residents. He stated the facility had a soda fountain at one time and residents could obtain soda during the day and evening but this was no longer an option due to cost. He commented soda is offered during some food related activities.",2017-10-01
7964,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-06-14,272,D,0,1,XGYR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined the facility failed to conduct assessments relative to urinary incontinence for one (1) of thirty-five (35) sampled residents. Resident #133 entered the facility with an indwelling catheter, when the catheter was discontinued and she had incontinence, no assessments were conducted to determine possible causal factors and how her incontinence might best be addressed. Resident identifier: #133. Facility census: 72. Findings include: a) Resident #133 During a review of the admission assessment, dated 03/09/12, it was discovered in Section H of the assessment, this resident had been admitted on [DATE] with an indwelling catheter. A review of the 14-day assessment, dated 03/15/12, found the resident no longer had a catheter and was frequently incontinent of bladder. This assessment also indicated no scheduled toileting or bladder training had been attempted. Review of the 30-day assessment, dated 03/29/12, found Section H was coded to indicate the resident was not always incontinent of bladder and no bladder training attempted. A review of the most recent quarterly assessment, dated 06/07/12, found Section H was coded as the resident being totally incontinent of bladder. During observations of the resident, on 06/12/12, it was noted the resident was alert, but did not speak English. During interviews conducted with direct care staff, it was revealed they communicated with the resident using pictures and gestures. During an interview with the director of nursing, Employee #07, on 06/13/12 at 3:45 p.m., it was confirmed there was no three (3) day voiding diary or other assessments done following admission in an attempt to discover the resident's voiding patterns and restore bladder continence to the extent possible.",2016-12-01
7965,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-06-14,280,D,0,1,XGYR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the care plan for one (1) of thirty-five (35) Stage II sample residents when the resident's medical [DIAGNOSES REDACTED]. Resident identifier: #58. Facility census: 72. Findings include: a) Resident #58 A review of Resident #58's care plan revealed a focus statement [DIAGNOSES REDACTED]. The goal statement was (resident's name) will remain free of complications associated with [MEDICAL CONDITION]. The interventions included Monitor for signs and symptoms of [MEDICAL CONDITION] (i.e., increased B.P. (blood pressure), increased heart rate, or increased appetite, irritability, hyper mood state, [MEDICAL CONDITION]). Another intervention stated Monitor for signs and symptoms of [MEDICAL CONDITION] (i.e., decreased B.P., decreased heart rate, weight gain, or decrease appetite, decrease energy, depression, increased sleeping). These interventions were initiated on 10/22/10. Although the names of the glands are similar, the [MEDICAL CONDITION] and [MEDICAL CONDITION] are entirely different glands, each produces distinct hormones with specific functions. The [MEDICAL CONDITION] secrete PTH, a substance that helps maintain the correct balance of calcium and phosphorus in the body. Symptoms are often mild and may be nonspecific - weakness, fatigue, depression, aches or pains, thinning of the bones which may increase the risk of fracture, kidney stones, etc. On 06/13/12 at 2:20 p.m., an interview was conducted with the director of nursing (DON). A request was made for clarification of what the nursing staff was monitoring, either hypo/[MEDICAL CONDITION] versus hyperparathroidism. On 06/14/12 at 8:15 a.m., an interview with the DON revealed Resident #58 had a history of [REDACTED]. She further stated no evidence could be found the resident had received any treatment for [REDACTED].#58 was being treated for [REDACTED].",2016-12-01
7966,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-06-14,312,D,0,1,XGYR11,"Based on observation, family interview, medical record review, and staff interview, the facility failed to schedule or assign nail care in order to maintain personal hygiene for two (2) of thirty-five (35) sampled residents. Residents #164 and #05 were observed to have long fingernails which were jagged on the edges and filled with debris. Resident identifiers: #164 and #05. Facility census: 72. Findings include: a) Resident #164 During the family interview, on 06/11/12 at 2:53 p.m., this resident was present. It was observed the resident had long fingernails that were jagged on the ends and filled with debris. Further observation of the resident, on 06/13/12 at 2:30 p.m., noted the resident's fingernails had not been trimmed and cleaned. Review of the resident's current comprehensive care plan, that addressed activities of daily living(ADLs) care, found nail care was not included in the interventions. The resident's care plan did indicate the resident required extensive assistance with ADLs. In an interview with the assistant director of nursing (ADON), Employee #54, on 06/13/12 at 2:55 p.m., it was revealed every resident received a shower/bath two (2) times a week, but nail care was done only when needed and was not done routinely with shower care. b) Resident #05 Observations of this resident, on 06/13/12 at 2:30 p.m., noted the resident's fingernails were long, jagged, and filled with debris. Review of the resident's current comprehensive care plan found nail care was not included in the interventions for ADLs. The care plan did indicate this resident required extensive assistance with ADLs. During an interview with Employee #54, on 06/13/12 at 2:55 p.m., it was revealed every resident received a shower/bath two(2) times a week, but nail care was not done routinely with shower care.",2016-12-01
7967,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-06-14,315,D,0,1,XGYR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined the facility failed to assess a resident's urinary incontinence and implement an appropriate plan in an attempt to restore as much normal bladder function as possible for one (1) of thirty-five (35) sampled residents. Resident identifier: #133. Facility census: 72. Findings include: a) Resident #133 Review of the admission minimum data set (MDS) assessment, dated 03/09/12, found this resident had been admitted on [DATE] with an indwelling catheter. According to the 14-day assessment, dated 03/15/12, the resident no longer had a catheter and was frequently incontinent of bladder. This assessment also indicated no scheduled toileting or bladder training had been attempted. The 30-day assessment, dated 03/29/12, indicated the resident was not always incontinent of bladder and no bladder training had been attempted. The most recent quarterly assessment, dated 06/07/12, indicated the resident continued to be totally incontinent of bladder. During an interview with the director of nursing (DON), Employee #07 on 06/13/12 at 3:45 p.m., it was confirmed there had been no attempt to restore urinary continence for this resident.",2016-12-01
7968,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-06-14,323,E,0,1,XGYR11,"Based on observations, review of manufacturer's warnings, review of materials safety data sheets, and staff interviews, the facility failed to provide an environment that was free from accident hazards over which the facility had control. Hazardous chemicals were stored on a shelf in the main shower room when a locked box was available for hazardous chemical storage. This practice had the potential to affect all cognitively impaired residents who wandered in the shower room and had access to the unlocked chemicals. Facility census: 72. Findings include: a) During a random tour of the facility, on 06/12/12 at 2:10 p.m., the room labeled Shower Room, was observed to have no lock on the door. Two (2) spray bottles containing a clear liquid were sitting on the shelf above the linen cart and one (1) was on the top shelf of the linen cart. Printed on one (1) bottle was bleach and the other bottle was labeled Triad. (Triad - a disinfectant which according to the information found on the website includes a warning of DANGER. CORROSIVE. CAUSES IRREVERSIBLE EYE DAMAGE. CAUSES SKIN BURNS. HARMFUL IF SWALLOWED OR INHALED. AVOID BREATHING SPRAY MIST.) There was a box with a key in the keyhole which was not locked on the wall beside the linen cart and shelf. Multiple bottles of personal care lotions, creams, deodorants and colognes were in the unlocked box. The director of nursing (DON) was asked to view the findings in the shower room, on 06/12/12 at 2:40 p.m. The DON immediately placed the bleach and Triad bottles in the locked box. She locked the box and agreed the bleach and Triad were to be stored in the locked box. In an interview, nursing assistant (NA) (Employee #4), agreed the personal care lotions, creams, deodorants and colognes were in the locked box during the 2:10 p.m. observation and had been thrown away because they were not supposed to be in the locked box. On 06/14/12 at 9:50 a.m., the maintenance director supplied the material safety data sheets (MSDS) for the bleach and Triad. He stated the housekeeping staff mixed the bleach solution and the solution was replaced when the bottle was empty. The bleach mixture was a 10:1 water to bleach solution. He further explained the Triad was also a mixed solution and was mixed according to manufacturer's directions. The MSDS for the Triad was reviewed and under Section 7. HANDLING AND STORAGE in the section Storage: Protect from . Keep tightly closed . KEEP OUT OF THE REACH OF CHILDREN. The MSDS for the bleach was reviewed and in Section IV Special Protection and Precautions the following statement was found: KEEP OUT OF THE REACH OF CHILDREN.",2016-12-01
7969,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-06-14,329,D,0,1,XGYR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of consultant pharmacist's reports, and staff interview, the facility failed to ensure each resident's drug regimen was free of unnecessary drugs. The facility failed to act upon the recommendations of the pharmacist for medications to be gradually reduced/discontinued for two (2) residents of thirty-five (35) sampled residents. Resident identifiers: #21 and #88. Facility census: 72. Findings include: a) Resident #21. Review of the medical record for Resident #21 identified the consultant pharmacist had recommended a gradual dose reduction, or discontinuation, for the benzodiazepine, [MEDICATION NAME], and the hypnotic, Ambien, on 04/16/12. Review of the Medication Administration Record [REDACTED]. On 06/13/12 at 10:05 a.m., Employee #7 (the director of nursing) confirmed the pharmacist made the recommendations, but the facility failed to alert the physician to the pharmacist's recommendations. b) Resident #88 Review of the medical record found the physician had not responded to the registered pharmacist's recommendation in January, 2012 for discontinuing the medication [MEDICATION NAME]. The pharmacist stated in his recommendation, dated 01/22/12, the resident had had little behaviors (sic) and suggested a trial discontinuance be implemented. Additionally, the medication [MEDICATION NAME] was to be given PRN (as needed) and it had been administered only one (1) time in November, 2011 and twice in October, 2011. There was no evidence the physician had made any response to that request. A consultant report from the pharmacist was blank in the signature area of the physician and had no other comments to explain a rationale for why this recommendation should not be followed. This was confirmed with the director of nursing (DON), Employee #7, at approximately 8:45 a.m., on 06/14/12, when she stated the physician had not made any type of response to the request.",2016-12-01
7970,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-06-14,371,F,0,1,XGYR11,"Based on observations and staff interviews, it was determined food items were not always stored, labeled, and dated in the kitchen and nourishment pantry areas. Also, food equipment in the dietary department needed cleaned. This had the potential to affect all residents who consumed foods by oral means, as all foods were served from this central location. Facility census: 72. Findings include: a) During observations on the initial tour of the dietary department, at lunch time on 06/11/12, it was noted three (3) carafes in the reach-in refrigerator contained beverages that did not have a label identifying the product or the date it had been opened. Another carafe was sitting on the counter and it also did not have a label or date. b) At this same observation time, the drip pan under the range top was found to have aluminum foil which was soiled with food debris and in need of cleaning/changing. This was discussed with the dietary manager, Employee #40, at 10:15 a.m. on 06/14/12, prior to exit. b) During random observations of the resident's nourishment pantry, on 06/11/12 at approximately 10:55 a.m., with Employee #67 (a nursing assistant), the following food items were found to be improperly stored. -- two (2) opened packages of sandwich cheese unwrapped and not dated -- an open cup of ice cream containing no lid and no date. -- two (2) bowls of pears with no date Employee #67 and Employee #7 (the director of nursing) confirmed the findings on 06/11/12 at 10:55 a.m.",2016-12-01
7971,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-06-14,372,F,0,1,XGYR11,"Based on observations and staff interview, it was determined staff had not disposed of all garbage and refuse in the appropriate manner. Observation of the dumpster area found the container piled high and the lid unable to close. Additionally, bags of trash were sitting directly on the ground next to the container. This has the potential to affect the whole facility as all trash was disposed of in this unit. Census: 72. a) Observation, on 06/13/12 at 1:20 p.m., revealed the dumpster was piled high with bags of trash and the lid was unable to be closed. Additionally, three (3) bags of trash were sitting directly on the ground next to the container. This practice has the potential of attracting vermin and other pests. This was discussed with the administrator, Employee #75, immediately after the observation.",2016-12-01
7972,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-06-14,428,D,0,1,XGYR11,"Based on review of medical records, review of consultant pharmacist's reports, and staff interview, the facility failed to act on pharmacist recommendations for three (3) of thirty-five (35) sampled residents. The pharmacist made recommendations for gradual dose reductions/discontinuation of medications for three (3) residents, but the facility failed to provide the information to the physician for review. Resident identifiers: #21, #88, and #36. Facility census: 72. Findings include: a) Resident #21 Review of the medical record for Resident #21 identified, the pharmacist had recommended a gradual dose reduction for the benzodiazepine, Ativan, and the hypnotic, Ambien. On 04/16/12, the consulting pharmacist reviewed the medications for Resident #21 and recommended these medications be gradually reduced/discontinued. Review of the Medication Administration Record [REDACTED]. On 06/13/12 at 10:05 a.m., Employee #7 (the director of nursing) confirmed the pharmacist had made the recommendations, but the facility had failed to inform the physician about the pharmacist's recommendations. b) Resident #88 Review of the medical record revealed the registered pharmacist had made a recommendation, dated 01/22/12, regarding the need for continued documentation for the use of psychoactive medications. The resident had been on Seroquel and Ativan prn (as needed) since May, 2011. She had had little agitated behaviors and Ativan had been administered only once in November, 2011 and twice in October, 2011. If this medication was to continue at the current dose, the physician needed to provide a rationale describing why a dose reduction was clinically contraindicated. The registered pharmacist consultant's report did not contain a signature or comments on the rationale for why the physician did not agree with this recommendation. A discussion with the director of nursing, Employee #7, at 9:10 a.m. on 06/14/12, verified that the physician had not responded as necessary to these recommendations. c) Resident #36 The medical record of this resident indicated the physician had not responded to the recommendation of the registered pharmacist to discontinue sliding scale insulin coverage and to begin fingersticks on Monday, Wednesday, and Friday before breakfast with no insulin coverage. The pharmacist's consultant report, of 03/15/12, contained no signature or documentation by the physician for the rationale of why the recommendation should not be implemented. Additionally, on the pharmacist's report, dated 04/16/12, it was shown that the pharmacist had recommended considering avoiding concomitant use of Fluoxetine HCL and Warfarin if possible. This medication may interact with Warfarin, whereby concurrent use may increase risk for medication-related toxicities, including bleeding. There was no evidence the physician gave a response to this recommendation. There was no signature or documentation of the rationale for why this recommendation should not be implemented. This too was verified with Employee #7 at 9:10 a.m. on 06/14/12.",2016-12-01
7973,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-06-14,431,E,0,1,XGYR11,"Based on observation and staff interview, it was determined the facility had failed to dispose of expired medications stored in the medication room refrigerator. Facility census was 72. Findings include: a) During an inspection of the medication storage room, and the medication refrigerator, on 06/12/12 at 1:45 p.m., ten (10) vials of influenza vaccine were found to have expiration dates of 05/20/12. Additionally, one (1) bottle of Vancomycin antibiotic, which had been reconstituted for a resident's use, had an expiration date of 05/26/12. During an interview with a licensed practical nurse (LPN), Employee #01, who was present during the inspection, it was confirmed the influenza vaccine and the bottle of Vancomycin had expired and should have been removed from the refrigerator.",2016-12-01
7974,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-06-14,441,F,0,1,XGYR11,"Based on observation, staff interview, and policy review, the facility failed to properly store clean linen (towels and wash cloths) in the shower room so as to minimize the potential for contamination. Further, the facility failed to ensure proper handwashing was practiced in the laundry department. These practices had the potential to affect all residents currently residing in the facility. Facility census: 72. Findings include: a) Observation, of the main shower room, on 06/12/12 at 2:10 p.m., revealed one cover panel on the linen cart was open. The cover panel was folded on top of the cart. On this same day at 2:40 p.m., the director of nursing (DON) observed one cover panel of the linen cart was open and folded on top of the cart. The DON agreed the linen cart was uncovered. On 06/13/12 at 9:54 a.m., a random tour of the main shower room revealed one cover panel of the linen cart remained folded on the top of the cart. At 10:00 a.m., the DON was informed the linen cart was again uncovered. The DON stated she would get a policy about linen carts being covered, including the linen cart in shower room. A review of the facility policy titled 2.3 Linen Handling, revealed under PROCESS, Section 1. Maintain clean linen in a closed storage area. 1.1 Keep clean linen covered. b) On 06/13/12 at 9:45 a.m., observation of the laundry, revealed laundry aide (Employee #65) entering the laundry, put on gloves and proceeded to take linen out of the washer, and put it into a clean linen cart. Employee #65 then put the linen in the dryer. This process was repeated for linens in the second washer. At that point, Employee #65 removed the gloves and put on another pair of gloves and proceeded to remove washed personal laundry and put it in the clean linen cart. The gloves were removed and another pair of gloves and plastic apron were put on. Employee #65 proceeded to put soiled personal laundry into the washer and then removed the gloves and apron. When Employee #65 was asked about the procedure for handwashing, the employee stated she did not wash her hands between changing gloves. She stated she was instructed that this was to be done and she failed to wash her hands when she removed her gloves.",2016-12-01
7975,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-06-14,465,E,0,1,XGYR11,"Based on staff interview and observation, the facility failed to ensure cleanliness of the refrigerator in the residents' nourishment pantry. The refrigerator used to store the residents' nourishments was found to be unclean on 06/11/12. Facility census: 72. Findings include: During random observation of the residents' nourishment pantry, on 06/11/12, the refrigerator used to store resident nourishments, was found to be unclean. The drawers on the bottom of the refrigerator failed to open due to a yellow sticky substance in the bottom of the refrigerator. Observation of the nourishment pantry was conducted with Employee #67, at approximately 10:55 a.m., on 06/11/12. The findings were immediately reported to Employee #7 (the director of nursing).",2016-12-01
8435,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2013-06-18,152,D,1,0,RXW311,"Based on record review and staff interview, the facility failed to follow the instructions that were given for allowing a resident to be taken out of the facility without permission from the legal guardian. Resident #50 was identified as a protected person and had a court appointed guardian/conservator. Written instructions were provided to the facility to indicate who was allowed to take the resident out of the facility. The facility did not follow the instructions and allowed the resident to leave the facility with a person who was not authorized to take the resident out of the facility. The court appointed guardian was not made aware the resident had left the facility. This was true for one (1) of five (5) sampled residents. Resident identifier: #50. Facility Census: 70. Findings include: a) Resident #50 It was recorded in this resident's medical record this resident had been determined by the Court to be a protected person. The Court had appointed a legal guardian to make decisions on the resident's behalf on 09/24/07. A review of the medical record, on 06/18/13, revealed a note that Resident #50 was not to leave the facility with anyone in his family. According to the note, he was only to leave with his court appointed guardian or her husband, whose name was specified. During an interview with the Administrator (Employee #83), it was verified that Resident #50 went out of the facility on 06/06/13 with an unauthorized person and went to his legal guardian's house without permission from the legal guardian. The facility had no knowledge of him leaving the facility until he returned. It was confirmed the facility did not follow the instructions of the legal guardian and failed to notify the responsible party that the resident wanted to go out of the facility with someone other than the individuals she had specified. The facility also failed to follow practices for signing out residents when they leave the facility.",2016-06-01
8436,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2013-06-18,166,D,1,0,RXW311,"Based on a review of the facility's customer and family concerns /grievances reports, family interview, and staff interview, the facility failed to acknowledge a complaint that was voiced by a responsible party. A complaint was filed with the facility administrator by Resident #50's legal decision maker, that a person who was not authorized to take the resident from the facility, had done so without permission. The complaint also voiced the facility staff had been dishonest with her and told her Resident #50 was in bed asleep when he was actually sitting in her living room. There was no evidence the facility recorded this complaint or investigated it to prevent this from reoccurring. This was true for one (1) of five (5) sampled residents. Resident identifier: #50. Facility Census: 70. Findings include: a) Resident #50 During an interview with the Social Worker (Employee # 57), on 06/18/13 at 12:00 p.m., it was identified Resident #50 had gone away from the facility and off the property without the permission of the legal guardian. She verified the guardian had a note in the front of the chart that the resident was not to be permitted to go out of the facility with anyone other than whom she had specified. She verified the resident's responsible party had come to the facility and she stated the administrator had talked to the responsible party. The administrator (Employee #83) was interviewed at 1:45 p.m. 06/18/13. He verified Resident #50's legal responsible party had called him and then came to the facility. The administrator said she voiced complaints that this resident was permitted to go out of the facility with an unauthorized person after she had told them not to permit him to go out. She also said the staff had not been truthful about where he was. He verified the responsible party had told him the resident was sitting in her living room and was not supposed to be allowed out of the facility. She also told him she called and asked someone at the nurses' station if she could talk to him and they told her he was asleep, then told her he said he would call her back. She verbalized the staff had not been truthful to her. He confirmed that he had not recorded these complaints and had no evidence he had made efforts to resolve the issues identified. According to a telephone interview, on 06/19/13 at 4:00 p.m., the resident's responsible party stated she had called the facility because the resident showed up at her house with an unauthorized person. She called the facility and told them the resident had called her and she needed to talk to him. The facility told her he was asleep. She told them it was an emergency and they told her to hold on. When they returned to the phone, they told her that the resident said he would call her back. She then stated that she knew this was not true because the resident was sitting in her living room. She said she hung up on them. After this took place, she came to the facility and told the administrator. The facility's complaint, grievance files, abuse/neglect reporting, and incident reports were reviewed. There was no evidence that the facility recorded this complaint and investigated it or made efforts to resolve grievances voiced by this resident's responsible party.",2016-06-01
8437,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2013-06-18,323,D,1,0,RXW311,"Based on record review and staff interview, the facility failed to ensure that a resident received adequate supervision to prevent accidents. Resident #50 did not have capacity, yet he went out of the facility with an unauthorized person against the directions given by the responsible party. The facility was not aware the resident had left the premises. This resident had been identified as a protected person by the court and a legal representative was selected as his decision-maker. Failure to provide supervision to prevent the resident from leaving the facility with an unauthorized person had the potential to result in a negative outcome . Resident identifier: #50. Facility Census: 70. Findings include: a) Resident #50 During an interview with the Social Worker (Employee #57), on 06/18/13 at 12:00 p.m., it was identified Resident #50 had left the facility with an unauthorized person without the permission of the legal guardian. She verified the guardian had a note in the front of the chart that he was not to be permitted to go out of the facility with anyone other than specific individuals. The person the resident left with was not authorized. The Social Worker verified that the facility's practice when a person left the facility was for release of responsibility for leave of absence form to be signed. This form was used to sign the resident in and out of the facility. She verified that no one had signed the resident out on 06/06/13 and this process was not followed. The Social Worker further identified this resident as an ambulatory resident who was permitted to go outside independently and liked walking around. She verified the facility did not have a process to know when he was outside, but he would tell someone. The administrator (Employee #83) was interviewed at 1:45 p.m. 06/18/13. He verified Resident #50's legal responsible party had called him and had come to the facility. She had voiced complaints that this resident had been permitted to go out of the facility with an unauthorized person after she had told them not to permit him to go out of the facility with anyone other than the individuals she had specified. The administrator had discussed this with the staff and it was confirmed no one was aware this resident,who did not have capacity,had left the facility. According to a telephone interview, on 06/19/13 at 4:00 p.m., the resident's responsible party stated that she called the facility because the resident showed up at her house with an unauthorized person. She called the facility and told them the resident had called her and she needed to talk to him. The facility told her the resident was asleep. She told them it was an emergency and they told her to hold on. When they returned to the phone, they told her that the resident said he would call her back. She then stated that she called this person a liar because the resident was sitting in her living room and hung up on them. After this took place, she came in the facility and told the administrator. She expressed the staff were not even aware he had left the grounds. It was determined this resident did not have adequate supervision, which allowed him to leave the grounds of the facility with an unauthorized person. He did not have capacity and was considered a protected person who was not safe and required supervision.",2016-06-01
9692,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,152,D,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to ensure each resident's health care decisions were made by the individual appointed by the resident. Additionally, determination of the resident's incapacity did not clearly indicate the nature of the incapacity. This was true for one (1) of thirteen (13) sampled residents. Resident identifier: #17. Facility census: 72. Findings include: a) Resident #17 1. Review of the resident's medical record found the resident had appointed Individual #1 as her first choice to be her medical power of attorney representative (MPOA). She had appointed Individual #2 as the successor MPOA should Individual #1 be unable, unwilling, or disqualified to serve. Further record review found Individual #2 had signed the physician's orders [REDACTED]. However, no evidence was found in the medical record indicating Individual #1 was unwilling or unable to serve, or that he had been disqualified. On the morning of 01/07/10, Employee #95 was asked whether something had happened to Individual #1, as Individual #2 had been making the resident's health care decisions. She said she did not know but would find the answer. At 9:20 a.m. on 01/07/10, Employee #95 said she had contacted Individual #2, who said she had been making the resident's health care decisions because Individual #1 had been working a lot of overtime. 2. This resident was admitted on [DATE]. A Physician Determination of Capacity had been completed on 12/10/09, by a physician other than the resident's primary physician. The form contained the following sentence: In my opinion this patient HAS ___ or LACKS ___ sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. The physician placed a checkmark in the blank beside Lacks. In a section directing Please check the nature of the incapacitation as evidenced by:, the evaluator recorded: Disorientation to person, place, and time. The word place had been circled. There was no check placed by Inability to understand or make medical decisions. This was discussed with Employee #95, who agreed it appeared the physician had indicated the resident was disoriented to place, which would not necessarily mean she was unable to understand the implications of health care decisions.",2015-10-01
9693,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,203,B,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's uniform notification of transfer / discharge form and staff interview, the facility failed to correctly communicate to all residents and responsible parties the contact information of the appropriate state agencies for residents with developmental disabilities or those who are mentally ill. This error in the uniform notice has the potential to lead a resident/responsible party to contact the wrong agency to provide assistance, and may interfere in the resident's ability to exercise his or her right to contact. The uniform discharge notice provided incorrect information regarding the agency designated in West Virginia to provide protection and advocacy to individuals with mental [MEDICAL CONDITION] and mental illness. This deficient practice has the potential to affect all residents of the facility with developmental disabilities or mental illness. Facility census: 72. Findings include: a) Review of the uniform notification of transfer / discharge form provided by the facility revealed the following: Or, for the resident with developmental disabilities or those who are mentally ill, you may contact: This was followed by the names and contact information for West Virginia Advocates Local Mental Health and Medicaid Fraud. This uniform notification form contained the following errors: - The single agency designated in WV to provide protection and advocacy to individuals with both mental [MEDICAL CONDITION] and mental illness is West Virginia Advocates, Inc, not West Virginia Advocates Local Mental Health. - Medicaid Fraud does not provide protection and advocacy services to persons with mental [MEDICAL CONDITION] and/or mental illness.",2015-10-01
9694,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,225,E,0,1,9PJH11,"Part I -- Based on personnel file review and staff interview, the facility failed to obtain statewide criminal background checks for eight (8) of ten (10) sampled employees, and failed to obtain an out of state background check for one (1) employee who had lived and/or worked in another state for many years. Employee identifiers: #19, #12, #59, #39, #30, #7, #72, and #76. Facility census: 72. Findings include: a) Employees #19, #12, #59, #39, #30, #7, #72, and #76 During review of sampled personnel records 01/05/10 at 1:30 p.m., Employee #89 agreed the following eight (8) employees had no evidence of having had a statewide criminal background check through the West Virginia State Police: Employees #19, #12, #59, #39, #30, #7, #72, and #76. Employee #89 confirmed Employee #30 had no out of state criminal background check for another state in which he resided for many years. Employee #19 was a nursing assistant whose services were being obtained through a temporary staffing agency. Her personnel filed contained a card, dated 09/29/09, stating a criminal background check through the West Virginia State Police was in progress with no results. Employee #89 said she would call the agency to obtain results, but nothing more was heard on the subject. These findings were reported to the director of nursing and the administrator at 3:30 p.m. on 01/07/10. No further information was provided. --- Part II -- Based on review of the facility's complaint files and reported allegations of resident abuse / neglect, and staff interview, the facility failed to thoroughly investigate and/or report all allegations of resident abuse / neglect to State agencies as required. Four (4) of nineteen (19) Complaint / Grievance forms reviewed contained allegations of physical and/or verbal abuse, or neglect. Resident identifiers: #79, #78, #77, and #65. Facility census: 72. Findings include: a) Resident #79 1. A Complaint / Grievance form, dated as received on 01/12/09, included: Resident stated, 'The CNA (certified nursing assistant) emptied my urinal & never returned it. I needed it & it wasn't by my bed. The CNA turned me extremely hard when changing me.' It was also noted on the page the concern was reported to the administrator, director of nursing, and a registered nurse supervisor. In response to the question What other action was taken to resolve concern (be specific)? was written CNA suspended until investigation completed and CNA to be educated. 2. A handwritten page, dated 01/13/09, was attached to the Complaint / Grievance form. The page had Incident Report written at the top, as well as the resident's name and the name of a licensed social worker (no longer an employee of the facility). The report included, Stated he drinks a lot of water and cannot go to the bathroom by himself and diaper got wet. So he rang the call light for help at 11:00 pm. A tall lady came in, . She was in a hurry and had a mean, hateful attitude, she pushed (resident's first name) over on his side, with such force, that he was afraid his pelvic bone might of been broken again, it hurt him. She changed his diaper & bed pad real quick with a mean, nasty attitude. She left then came back at 12:00 midnite made a remark and accused (resident's first name) of keeping his roommate awake. After she left, he was under tremondous (sic) stress and could not find the urinal and he thought she had left the urinal in the bathroom on purpose and he did not have access to it, he felt that she did it on purpose. So he urinated in the plastic glass on the bedside table, and then he dumped it on the floor. Then he looked for the call button and could not find it, then he saw it on the chair, where the lady had set it, he asked his room mate (sic) if he could reach it and push it, but he was not able to. (Resident's first name) continued struggling and reached through the side bar and got the call light, but decided he did not want the lady to return. He did not sleep and waited until 6:00 AM for the fay shift. Then he rang the button, . He was d___ (illegible) and exhausted. (Resident's first name) said it was a violation and his room mate could verify it, because he could not sleep on account of his pain level. He will D/C (be discharged ) to home on 1-14-09 at 8:00 pm. The last page regarding this complaint / concern was an immediate fax reporting of allegations to the nurse aide registry. The only items marked on the form were No in answer to the question Is this report being submitted within 24 hours of the incident?, and UTD (unable to determine) exact date of incident in response to If No, please explain. The remainder of the form was blank. The alleged perpetrator's name did not appear on any of the three (3) pages. This report was compared to those that had been reported to State agencies, i.e., the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Ombudsman. There was no evidence the incident had been reported. The social worker and the director of nursing identified in the report were no longer employed by the facility. b) Resident #78 A Complaint / Grievance form, dated as received on 05/17/09, included Resident had c/o (complaint of) care given her by CNA. CNA assigned to resident was (CNA's first name). Resident stated she told CNA she was wet and sheets were wet. Resident reported that CNA stated, 'Well there is a first time,' did not (symbol for change) resident, resident laid in wet bed. Employee #74 noted she had spoken with the CNA about the resident's concerns. She wrote, CNA defensive in reply - 'she doesn't like us (names of two (2) CNAs). It was also noted the resident's bed was changed and the CNA apologized. There was no evidence this allegation was reported to the required agencies. c) Resident #77 On 05/16/09, a Complaint/Grievance form was initiated for Resident #77. He reported his call bell was not answered in a timely manner, he did not get help to the bathroom, and his medications were not given at the correct time. The investigator noted she spoke with the CNA and the nurse assigned to the resident. It was not noted whether the issue had or had not been verified. From the verbiage of the report, it appeared the resident's complaints were not limited to an isolated incident; however, there was no evidence any interviews were conducted other that the resident and his spouse, one (1) CNA, and one (1) nurse. There was no evidence this was reported to the State agencies. d) Resident #65 A Complaint / Grievance form, dated as received on 02/02/09, noted, Resident was crying in her room said '(employee's name) hates me.' She said that her nurse waved her 'Finger' in my face.' The social worker (Employee #95) noted, Met with resident, she related that there was no problem, that she and her nurse have difference (sic) of opinion and that is between them. There was no evidence of interviews with the nurse or any other staff regarding the incident. There was no evidence this allegation had been reported to the State agencies. e) These issues were discussed with the Employee #95 the afternoon of 01/07/10 with no additional information provided.",2015-10-01
9695,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,272,D,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, the facility failed to ensure an accurate assessment of a resident's urinary continence status had been completed. Documentation of the summary information regarding additional assessment, performed through the resident assessment protocols (RAPs), was not in agreement with the coding on the minimum data set assessment (MDS) that triggered completion of the RAP. Resident identifier: #32. Facility census: 72. Findings include: a) Resident #32 The significant change in status MDS, with an assessment reference date (ARD) of 08/12/09, indicated the resident was usually continent of bladder. The significant change in status MDS assessment, with an ARD of 10/10/09, indicated the resident was frequently incontinent of bladder. The RAP for 'Urinary Incontinence and Indwelling Catheter' completed for the latter, on page 9 of 27, included, RAP triggered by: H1b = 3 FREQUENTLY INCONTINENT. A few lines below that, under Nature of the problem / condition; a nurse had written, Resident has impaired cognition secondary to effects of [MEDICAL CONDITION] disorder she has occasional episodes of urinary incontinence. See urinary incontinence assessment 08/22/09, see CNA flow sheet 09/27/09 - 10/10/09. On page 10 of 27, the RAP was continued. In the section for Describe impact of this problem / need on the resident and your rationale for care plan decision (Include complications and risk factors and the need for referral to other health professionals): the nurse wrote, Resident triggered on this rap d/t (due to) occasional urinary incontinence. The RAP had been completed by a registered nurse (RN) whose name did not appear on the current employee list, and it was co-signed by Employee #84. Although the computer-generated RAP form had identified the resident as frequently incontinent of urine, the assessor wrote the resident was occasionally incontinent of urine. There was no indication the decline in continence had been identified by the assessor and/or attempts made to determine potentially reversible causes, nor had it been indicated the decline was transient and had only been evident during the assessment look-back period.",2015-10-01
9696,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,279,D,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to ensure each resident's care plan included measurable goals and interventions that contributed to the achievement of established goals, and failed to establish care plans that addressed the individual's needs as identified by the resident's assessment. Three (3) of thirteen (13) current residents on the sample were affected. Resident identifiers: #17, #32, and #22. Facility census: 72. Findings include: a) Resident #17 1. The resident's admission minimum data set assessment (MDS), with an assessment reference date (ARD) of 12/16/09, was coded to indicate she was occasionally incontinent of bowel and bladder. The urinary incontinence resident assessment protocol (RAP) was triggered due to the occasional incontinence and the use of pads or briefs coded on the assessment. The RAP narrative, completed on 12/23/09, also noted the resident was occasionally incontinent of urine. The problem statement identified in the care plan was: (Resident #17's first name) is frequently incontinent of bowel and bladder and is unable to cognitively or physically participate in a retraining program due to cognitive loss, right [MEDICAL CONDITION]. The frequency of the incontinence, as identified on the RAP completed 12/23/09, was not reflected on the goal established on 12/23/09. 2. The resident's MDS also identified the resident required the limited assistance of one (1) for eating. The care plan goal, established on 12/23/09, was for the resident to remain independent in eating. This did not reflect the resident's functional abilities identified on the resident's assessment. The interventions included: Shower and shampoo per schedule; Change clothing when soiled; clean and clip nails; etc. The only intervention related to promoting independence in eating was: Encourage resident out of bed for all meals. 3. Several of the goal statements did not include parameters by which progress (or lack of progress) toward achievement of the goal could be determined. An example was: Resident will increase social engagement as evidenced by participation in one to one visits, small groups and unstructured involvement with peers / family / friends / staff. This did not identify a frequency so it could be determined whether there was an increase in her social engagement. 4. A problem statement was: (Resident's first name exhibits distressed mood symptoms as evidenced by: sadness / depression anxiety. The associated goal was: Will have smallest most effective dose of medication as possible thru 90 day review. There was no indication of what type of medication the resident was to receive the smallest dose. b) Resident #32 1. The resident had a significant change MDS, with an ARD of 08/12/09, the identified the resident as being usually continent of urine. The significant change MDS, with an ARD of 10/10/09, was coded as the resident being frequently incontinent of urine. The resident's current care plan did not address the increase in incontinence as identified by her assessment. 2. The care plan also included a goal of: The Resident will experience maximum peripheral circulation without complications x 90 days. The interventions for this goal were all to assess and/or monitor. There were no interventions to promote maximum peripheral circulation. 3. Another goal was: (Resident #32's first name) will make safe daily decisions / choices when provided with cues and supervision throughout review. In the problem statement, it was noted the resident exhibited poor safety awareness at times such as ambulating alone with out her walker or wheelchair. The interventions were: Approach the resident in a calm, non-threatening manner; Staff will provide consistency in daily routine; Allow the resident to make daily decisions about clothing, daily care, meal alternatives, etc.; Provide daily schedule in room; Be alert to non-verbal clues of problems. There was nothing in approaches related to ambulating safely. c) Resident #22 Review of the RAP summary, dated 12/09/09, revealed the decision to care plan in multiple areas including cognitive, communication, activities of daily living, incontinence, moods, behaviors, falls, nutrition, fluid balance, pressure ulcer, and [MEDICAL CONDITION] medication. However, review of the current care plan, provided by the director of nursing on 01/05/10, revealed care plans for only five (5) of the above eleven (11) areas cited were developed. Concerns related to communication, activities of daily living, incontinence, mood, behaviors, and [MEDICAL CONDITION] medications were not mentioned in the care plan. During interview with the director of nursing on 01/07/09 approximately 9:30 a.m., these findings were discussed. No further evidence was produced prior to exit.",2015-10-01
9697,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,280,D,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, resident interview, and staff interview, the facility failed to revise each resident's care plan as changes occurred in care needs and/or the services they received. Two (2) of thirteen (13) current residents on the sample were affected. Resident identifiers: #46 and #41. Facility census: 72. Findings include: a) Resident #46 Review of the medical record revealed Resident #46 developed a Stage II pressure ulcer to the coccyx identified on 12/15/09. physician's orders [REDACTED]. Interview with a nurse (Employee #67), on 01/06/10 at 10:00 a.m., revealed this resident repeatedly had experienced the recurrent development and healing of Stage II decubitus ulcers to the coccyx due, in part, to his being non-compliant with repositioning. Review of the current care plan revealed no mention of this resident having a Stage II decubitus ulcer, nor of his being non-compliant with repositioning; rather, the care plan stated: Stage I area on coccyx will decrease in size through 90 day review. During interview with the director of nursing (DON) on 01/07/09 at approximately 9:30 a.m., this finding was discussed with no new information provided prior to exit. b) Resident #41 1. Review of the RAP, dated 10/12/09, revealed the decision to care plan for [MEDICAL CONDITION] medication, but this did not occur. Review of the current care plan did not address or mention [MEDICAL CONDITION] medication. Review of current physician's orders [REDACTED]. 2. Review of the current care plan revealed a statement to comply with diet restrictions. However, he had none. Review of current physician's orders [REDACTED]. Carb Controlled. Review of the November 2009 Report Card from the [MEDICAL TREATMENT] center revealed hand-written suggestions for a high protein diet with supplement, and binders with all meals / snacks. 3. Review of the care plan revealed an intervention to Administer [MEDICATION NAME] as ordered. However, review of physician's orders [REDACTED]. 4. Review of the current care plan revealed plans to Weigh as ordered and Monitor weight per policy and report to dietician and physician (of) significant loss or gain. The care plan did not specify how often to weigh the resident. During an interview with the resident on 01/06/09, he stated he was weighed at the [MEDICAL TREATMENT] center before and after each [MEDICAL TREATMENT] treatment three (3) days per week. The physician's orders [REDACTED]. 5. Review of admission orders [REDACTED]. Review of the care plan revealed it was not revised to include contact precautions nor the [DIAGNOSES REDACTED]. 6. During interview with the DON on 01/06/10 at 5:50 p.m., the findings of care planning not being specific enough for this resident were discussed, as well as unclear communications in the care plan regarding coordination of services between the [MEDICAL TREATMENT] center desires and the facility. The DON said they were operating on new physician orders [REDACTED]. 7. Review of the care plan revealed special precautions were not cited with respect to the location of the resident's vascular access for [MEDICAL TREATMENT], such as no blood pressure on extremity, no intramuscular injections in extremity, no limb restraint. It did, however, call for smooth clamps at bedside, 4x4 gauze pads and cloth tape at bedside. Interview with the DON and administrator, on 01/07/10 at 3:30 p.m., revealed their understanding of a vas-cath, which did not require the presence of clamps and gauze at the bedside. No further information was received regarding the above findings.",2015-10-01
9698,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,285,D,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the resident's medical record, the facility failed to ensure the pre-admission screening and resident review (form PAS-2000) was completed prior to the resident's admission to ensure she was placed in the most appropriate setting. One (1) of thirteen (13) current residents on the sample was affected. Resident identifier: #17. Facility census: 72. Findings include: a) Resident #17 review of the resident's medical record revealed [REDACTED]. The PAS-2000, pages 2 through 5, had been faxed from the hospital to the facility on [DATE]. However, page 6 of the document - the Eligibility Determination - was not completed by the reviewer and faxed to the facility until 12/10/09, the day after she had been admitted . The Eligibility Determination must be completed prior to admission to the nursing home to ensure the level of care and setting are appropriate for the individual.",2015-10-01
9699,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,311,D,0,1,9PJH11,"Based on observations, the facility failed to ensure each resident received services to maintain or improve the resident's ability to eat. Three (3) residents, who were observed at random during the initial tour of the facility, were not seated or positioned in a manner to facilitate the resident's ability to feed herself. Resident identifiers: #8, #44, and #45. Facility census: 72. Findings include: a) Resident #8 At lunch time on 01/04/10, the resident was observed eating in the TV/dining area near the nurses' station. The resident was seated in a small wheelchair. Her meal had been placed on an overbed table in front of her. The plate of food had been left on the warming base atop the tray. This resulted in the resident's food being at the height of her chin. She had to raise her hand and elbow to above shoulder height to reach her food. b) Resident #44 At lunch time on 01/04/10, this resident was also observed eating in the TV/dining area near the nurses' station. The resident was seated in a recliner being fed by a staff member. The recliner had not been raised, resulting in the resident being fed while at a 45 degree angle. c) Resident #45 At lunch time on 01/04/10, this resident was observed eating in her room. The resident was seated in recliner, and her food was on an overbed table. The plate on the overbed table was at the height of the resident's nose.",2015-10-01
9700,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,314,D,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide care and services in accordance with physician orders [REDACTED]. There was no evidence a dressing to Resident #46's coccyx was changed every three (3) days in December 2009 and January 2010 as ordered by the physician. Resident identifier: #46. Facility census: 72. Findings include: a) Resident #46 Review of this resident's medical record revealed a lack of evidence treatments were a Stage II pressure ulcer to the coccyx were provided as ordered by the physician. Review of physician's orders [REDACTED]. Review of Resident #46's treatment administration record (TAR), on 01/06/09, revealed an order, initiated on 12/15/09, to cleanse, dry, and apply an Exuderm dressing to the coccyx every three (3) days and as needed for a Stage II pressure ulcer. Review of the December 2009 TAR revealed the nurse initialed the TAR on 12/15/09, signifying a dressing change was completed on that date. According to the order, the dressing was to have been changed on 12/18/09 and again on 12/21/09, but neither block was initialed by a nurse to indicate these had been completed. A dressing change was initialed as completed on 12/23/09. Three (3) days later, on 12/26/09, and again on 12/29/09, there were no initials signifying dressing changes were completed on these dates. Three (3) of six (6) scheduled dressing changes did not occur in accordance with the physician's orders [REDACTED]. Review of the TAR for January 2010 revealed the dressing was scheduled to have been changed on 01/02/10 and 01/05/10; however, there was no documentation on the TAR or in the nursing notes signifying any dressing changes had been completed in January prior to 01/06/10. Interview with the nurse (Employee #67), on 01/06/09 at 10:00 a.m., revealed, on 11/27/09, the resident's left buttock was reddened and, on 12/23/09, a Stage II pressure ulcer re-opened on the resident's coccyx. Employee #67 related the wound on the coccyx repeatedly healed and reopened due, in part, to the resident's refusals to be repositioned for pressure relief. After looking at the resident's records, she agreed no dressing changes to the coccyx were documented since January 2010, and the last wound measurements she could find on the TAR were recorded on 12/23/09. She noted this resident's dressing was changed on day shift, and she typically worked another shift. Interview with the director of nursing (DON), on 01/06/09 at 10:40 a.m., revealed their former treatment nurse quit suddenly and without notice, and they were in the process filling that position. In the interim, she informed all nurses they were responsible for dressing changes for their shifts until another treatment nurse was assigned. She said she could not address why dressing changes to the coccyx were not documented, but she stated it was certainly an expectation that nurses will document what they do. Because of the problems surrounding the treatment nurse position, she stated the facility conducted a skin sweep of all residents on 12/30/09. Subsequently, the DON produced a Wound Management Tracking Tool for Resident #46 which contained measurements of the coccyx pressure ulcer (1.5 cm x 1.0 cm.) on 12/30/09. She stated this was a tool which had been available but not used until recently, as she had held the director of nursing position for only the past two (2) weeks. Besides weekly measurements to assess wound healing, she stated measures to promote the healing process for this resident included a pressure reducing mattress, a foam pillow in his wheelchair, and a house supplement twice daily. She acknowledged that his refusal to allow staff to turn him was an issue with wound healing. During observation of the dressing change on 01/06/09 at 5:00 p.m., the medication nurse (Employee #70) measured the Stage II pressure ulcer on the coccyx at 0.9 cm x 0.8 cm. Comparatively, measurements dated 12/30/09 on the Wound Management Tracking Tool were 1.5 x 1.0 cm; and measurements on the Skin Integrity Report dated 12/23/09 were 1.0 cm x 0.9 cm.",2015-10-01
9701,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,315,D,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to ensure each resident received treatment and services to restore as much normal bladder function as possible. Voiding diaries were not completed for two (2) residents, nor was there any analysis of patterning from available data. One (1) resident had experienced a decline in urinary continence, but there was no evidence the cause of the decline had been assessed to determine whether it was reversible. Three (3) of thirteen (13) current residents on the sample were affected. Resident identifiers: #73, #32, and #22. Facility census: 72. Findings include: a) Resident #73 This resident had been admitted to the facility on [DATE]. The resident's admission minimum data set assessment (MDS), with an assessment reference date (ARD) of 11/27/09, indicated the resident was INCONTINENT - Had inadequate control BLADDER, multiple daily episodes; . The assessment also identified the resident had deteriorated in urinary continence in the last ninety (90) days. According to documentation found on the resident assessment protocol (RAP) for urinary incontinence, Resident has a [DIAGNOSES REDACTED]. He has declined in physical functioning d/t hospitalization for UTI (urinary tract infection) and dehydration and is having total urinary incontinence. Staff is going to try toileting program but potential maybe poor d/t cognitive deficit. He is also receiving OT (occupational therapy) for toileting. See hospital summary, incontinence assessment, CNA flow sheet OT eval 11/20/09 - 11/27/09. The RAP was also checked for UTI and locomotion. In the narrative section, the assessor noted the resident did have potential for some continence and that a toileting diary would be completed. A Urinary Incontinence Assessment was completed at the time of admission on 11/20/09. The following were noted: 1. In the section for Clinical Factors, an x had been place by None for Change in urinary status. It was also marked that he did not have stress or urge incontinence or retention with overflow. 2. An x had been place by Signs and symptoms of [MEDICAL CONDITION]. The RAP guidelines identify [MEDICAL CONDITION] as an acute medical emergency. Therefore, the [MEDICAL CONDITION] should have been further assessed prior to making a determination regarding his ability to participate in retraining program. 3. The nurse had placed an x by If no clinical symptoms or transient / reversible causes identified OR unable to be reversed (e.g. meds cannot be changed), urinary incontinence is persistent. Initiate Three-Day continence Management Diary and Proceed to Section B. An x had also been placed by If clinical symptoms or reversible/transient causes identified, develop plant to treat (e.g., evaluate and treat symptomatic UTI). Notify physician for treatment orders. Re-evaluate after treatment. There was no evidence the resident was re-evaluated after his [MEDICAL CONDITION] had been assessed further or after his medications were changed. He had been admitted on [MEDICATION NAME] and [MEDICATION NAME]. The [MEDICATION NAME] had been decreased on 11/25/09. (It was noted in an interdisciplinary note the family had wanted him taken off of the medications, because he had not taken any before.) 4. On the second page of the assessment, Section B, under Action: 1. Identify the type of urinary incontinence based on history and symptoms: the nurse had written Urge, Stress, Mixed, Functional. This was not in agreement with what had been marked on the first page, where it had been marked the resident did not have urge or stress incontinence. 5. The Three-Day Continence Management Diary was reviewed. The dates on the diary were 11/22/09, 11/23/09, and 11/24/09. The form had boxes to be completed on an hourly basis from 7:00 a.m. through 6:00 a.m. - a total of twenty-four (24) boxes for each day. - On 11/22/09, the 7:00 a.m., 10:00 a.m., and 3:00 p.m. boxes were marked for episodes of urinary incontinence. He was marked as being clean and dry six (6) times between 7:00 a.m. and 3:00 p.m. The boxes for 4:00 p.m. through 10:00 p.m. were blank. Between 11:00 p.m. through 6:00 a.m., he was marked as incontinent three (3) times, and as clean and dry five (5) times. - On 11/23/09, nothing was marked in the boxes from 7:00 a.m. through 10:00 p.m. From 11:00 p.m. through 6:00 a.m., he was marked as incontinent three (3) times, and clean and dry five (5) times. - On 11/24/09, between 7:00 a.m. and 2:00 p.m., boxes were marked for episodes of urinary incontinence once for bowel incontinence, and once for urinary incontinence. He was marked as being clean and dry six (6) times between 7:00 a.m. and 2:00 p.m. The boxes for 3:00 p.m. through 10:00 p.m. were blank. Between 11:00 p.m. through 6:00 a.m., he was marked as incontinent two (2) times, and as clean and dry six (6) times. Of the seventy-two (72) hours on the three-day voiding diary, only forty-one (41) had been completed to show whether or not the resident had been incontinent. The times the diary had been completed showed he had had been clean and dry up to four (4) hours. This would indicate the resident had some control over his bladder. There was no evidence the resident's voiding pattern had been reviewed, that he had been re-evaluated once his [MEDICAL CONDITION] cleared, or once his medications had been decreased / discontinued. There was no evidence he had been evaluated to ensure he was consuming sufficient fluids to promote continence. The elements needed to determined what type of program might best suit the resident's unique needs were not in evidence. The care plan indicated he was on a scheduled toileting plan and the goal was for him to have less than two (2) urinary incontinent episodes daily. The interventions did not offer any specific intervals at which he should be toileted. The interventions instructed he be assisted to toilet upon arising, before / after meals, before going to bed and as needed and at night, when he was awaken during rounds. This was discussed with the director of nursing in mid morning on 01/07/09. b) Resident #32 Review of the resident's significant change MDS assessments, with ARDs of 08/12/09 and 10/10/09, found the resident had been assessed as usually continent of urine in August, and frequently incontinent of urine in October. The urinary incontinence RAP, completed for the 10/10/09 assessment, was noted to have triggered because she was frequently incontinent. However, the narrative sections noted the RAP had triggered because she was occasionally incontinent. There was nothing to indicate she had only been frequently incontinent during the assessment reference period. The coding on the Activities of Daily Living Flow Chart for October 2009 indicated the resident was frequently incontinent during the look-back period for the assessment. She continued to be frequently incontinent the remainder of October 2009. The only additional assessment found for urinary incontinence was a Urinary Incontinence Assessment dated 08/22/09, which noted the resident was continent. The resident's care plan did not address her urinary incontinence. c) Resident #22 Review of the medical record revealed a Three-Day Continence Management Diary dated 11/24/09 at the time of admission. The instructions on this form state the diary must be initiated within seventy-two (72) hours of identifying incontinence or completion of treatment for [REDACTED]. Further review of the diary revealed this resident was checked on 11/25/09 at 11:30 p.m. and was found to be dry. No other assessments were entered on this form, and no other Three-Day Continence Management Diary was found in the medical record. However, review of the admission MDS found the assessor coded the resident's urinary continence status in the preceding fourteen (14) days as being frequently incontinent; i.e., tended to be incontinent daily, but some control is present. These two (2) assessments are contradictory. Review of Daily Skilled Nurse's Notes, dated 12/08/09, revealed this resident was incontinent of bowel and bladder most of the time, with bladder incontinence checked for both evening and night shifts. Review of lab work, dated 11/26/09, revealed Resident #22's white blood count was elevated at 12.7 and the lymphocytes were low at 15.2, indicative of bacterial infection; UTI (urinary tract infection) was hand written beside the white blood count. The urinalysis on the preceding day showed evidence of a urinary tract infection, and a hand-written note on the urinalysis report recorded the resident was on an antibiotic twice daily for seven (7) days beginning on 11/26/09 for a urinary tract infection. Also, a hand-written note on the physician's orders [REDACTED]. Additionally, the Medication Record for November 2009 contained an order for [REDACTED]. Review of the RAP summary completed in conjunction with the admission MDS revealed the decision to care plan for the resident's urinary incontinence. However, review of the care plan revealed no focus or interventions for incontinence, nor any mention of a voiding diary for analysis of the problem. These findings were discussed with the director of nursing on 01/07/09 at 9:30 a.m., and no further information was presented prior to exit.",2015-10-01
9702,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,431,E,0,1,9PJH11,"Based on observation and staff interview, the facility failed to label / date all vials of injectable insulin when initially opened, and failed to discard vials of injectable insulin after the allowed thirty (30) day time limit after opening the vial had elapsed. This was evident for two (2) of four (4) medication carts observed in the facility and had the potential to affect diabetics who receive insulin on the 100 and 400 hallways. Facility census: 72. Findings include: a) Observation of the medication cart on the 400 wing, on 01/06/10, revealed the presence of one (1) vial of Novolin-N inscribed with the date of 11/06/09 to indicate the date it had been opened, and one (1) bottle of Novolog inscribed with the date of 11/15/09 to indicate the date it had been opened. Both vials were prescribed for Resident #12. Additionally, a vial of Novolin-R was opened and had no date inscribed on the vial to indicate when it had been opened; this was prescribed for Resident #58. The nurse (Employee #78) acknowledged staff was to inscribe the date the vials were opened and discard the vials after having been opened for thirty (30) days. b) Observation of the medication cart on the 100 hall, on 01/06/10, revealed one (1) vial of Novolog was opened and inscribed with the date of 11/28/09 for Resident #3. The nurse (Employee #58) acknowledged staff was to inscribe the date the vials were opened and discard the vials after having been opened for thirty (30) days. c) Both medication nurses discarded the above four (4) vials of insulin and planned to reorder. d) During interview with the director of nursing on 01/07/10 at approximately 9:30 a.m., she was made aware of the above findings. No new information was provided at this time.",2015-10-01
10073,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-03-01,164,D,1,0,0TSC11,". Based on observation, the facility failed to ensure personal privacy was maintained during a nursing procedure for one (1) of nine (9) sampled residents. Resident identifier: #33. Facility census: 71. Findings include: a) Resident #33 During random observations, conducted on 02/29/12 at 11:15 a.m., a registered nurse (RN), Employee #31, was observed flushing Resident #33's gastrostomy tube. It was noted the roommate and two (2) visitors were in the room and were watching the procedure. The nurse exposed the resident's abdomen and failed to pull the curtain between the beds or close the door to the hallway. The resident's gastrostomy tube and abdomen were clearly visible from the hallway, as was the procedure performed by the RN. .",2015-07-01
10074,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-03-01,225,D,1,0,0TSC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on facility document review and staff interview, the facility failed to ensure all allegations of neglect were reported to state agencies as required, and were thoroughly investigated. This deficient practice affected one (1) of nine (9) sampled residents. The resident's daughter made an allegation of neglect which was not investigated or reported by the facility. Resident identifier: #73. Facility census: 71. Findings include: a) Resident #73 Review of a facility document, dated 02/13/12, entitled ""Record of Customer and Family Concerns,"" found the social worker, Employee #79, contacted the resident's daughter after the resident's admission to the hospital on [DATE]. Employee #79 documented the daughter ""had some concerns about resident's condition prior to admission to hospital (sic)"". Employee #79 further documented the nursing home administrator and director of nursing were informed. Employee #79 documented the daughter reported Resident #73 had bilateral pneumonia. Employee #79 further documented the daughter was upset with the facility ""...because we did not check on her often because if we did this wouldn't have happened."" Employee #79 documented the daughter stated, ""...she came in on Wed. 01/31/12 and her mother appeared dehydrated, (her mouth was dry and tongue sticking to roof of mouth). (The Daughter) notified a nurse (couldn't recall name or identify), however nurse shrugged it off. (The daughter) gave her mother water and she seemed better. Monday 2/6/12, (the daughter) came to see (Resident #73) again (around end of dinner) and found her shaking and appearing dehydrated. (The daughter) also reports that her tube feed was dated for 2/4/12 and crusted around opening at stomach. (The daughter) reports that her mother was not talking or acknowledging her presence. (The daughter) went to get a nurse, but felt the nurse shrugged it off and ignored her concerns. (The daughter) continued to express concerns to nurse. (The daughter) said nurse told her she was shaking due to [MEDICAL CONDITION] Dx (diagnosis). (The daughter) told nurse she did not have [MEDICAL CONDITION]. Nurse took vitals and agreed to contact physician. (The daughter) stated she insisted that facility send her mother out. When (Resident #73) arrived @ (at) the hospital, (The Daughter) reports, the physician told her to call in family because (Resident #73) was almost dead. (The Daughter) reports that ER (emergency) physicians cautioned her against sending her back to (the facility)..."". An interview with Employee #79, on 02/28/12 at 4:30 p.m., revealed the facility had not investigated nor reported the allegations of neglect made by Resident #73's daughter. .",2015-07-01
10075,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-03-01,279,D,1,0,0TSC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, medical record review, resident interview, and staff interview, the facility failed to ensure a comprehensive care plan for one (1) of nine (9) sampled residents was developed to meet resident's medical and nursing needs. The facility failed to include a physician's orders [REDACTED].#60 was to have no water until her sodium levels normalized. Observations found the resident to have a pitcher of ice water at the bedside. Additionally, resident interview found the resident was unaware of this restriction. Resident identifier: #60. Facility census: 71. Findings include: a) Resident #60 Review of the medical record found a physician's orders [REDACTED]. An interview with the director of nursing (DON), Employee #6, on 02/29/12 at 3:40 p.m., elicited that ""free water"" meant plain water. Resident #60's room was entered at 3:41 p.m. on 02/29/12. Observation revealed a pitcher of ice water on her bedside table. The resident was alert and oriented. She was asked if she was allowed to have water. The resident responded, ""I can have all the water I want."" The facility provided no evidence the resident was educated concerning the physician's orders [REDACTED]. Further review of the medical record found the physician's orders [REDACTED]. .",2015-07-01
10076,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-03-01,309,G,1,0,0TSC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, review of information from hospital records, observation, resident interview, and staff interview, the facility failed to assess a resident ' s clinical and mental status, failed to monitor the resident ' s response to treatment, and failed to obtain laboratory studies as ordered by the physician. These deficits in care resulted in a finding of actual harm to Resident #73. It was also determined a potential for more than minimal harm existed for Resident #60, by the facility ' s failure to implement a physician ordered fluid restriction. Two (2) of nine (9) residents on the sample were affected. Resident identifiers: #73 and #60. Facility census: 71. Findings include: a) Resident #73 1) Review of a facility document, dated 02/13/12, entitled ""Record of Customer and Family Concerns,"" found the social worker, Employee #79, contacted the resident's daughter after the resident's admission to the hospital on [DATE]. Employee #79 documented the daughter ""had some concerns about resident's condition prior to admission to hospital (sic)"". Employee #79 further documented the nursing home administrator and director of nursing were informed. Employee #79 documented the daughter reported Resident #73 had bilateral pneumonia. Employee #79 further documented the daughter was upset with the facility ""...because we did not check on her often because if we did this wouldn't have happened."" Employee #79 documented the daughter stated, ""...she came in on Wed. 01/31/12 and her mother appeared dehydrated, (her mouth was dry and tongue sticking to roof of mouth). (The Daughter) notified a nurse (couldn't recall name or identify), however nurse shrugged it off. (The daughter) gave her mother water and she seemed better. Monday 2/6/12, (the daughter) came to see (Resident #73) again (around end of dinner) and found her shaking and appearing dehydrated. (The daughter) also reports that her tube feed was dated for 2/4/12 and crusted around opening at stomach. (The daughter) reports that her mother was not talking or acknowledging her presence. (The daughter) went to get a nurse, but felt the nurse shrugged it off and ignored her concerns. (The daughter) continued to express concerns to nurse. (The daughter) said nurse told her she was shaking due to [MEDICAL CONDITION] Dx (diagnosis). (The daughter) told nurse she did not have [MEDICAL CONDITION]. Nurse took vitals and agreed to contact physician. (The daughter) stated she insisted that facility send her mother out. When (Resident #73) arrived @ (at) the hospital, (The Daughter) reports, the physician told her to call in family because (Resident #73) was almost dead. (The Daughter) reports that ER (emergency) physicians cautioned her against sending her back to (the facility)..."". 2) Nursing entries for Resident #73 Review of the medical record found the treating physician determined this resident retained the capacity to make medical decisions. Review of nursing notes on 01/29/12 and 01/31/12 found the resident described as ""alert and oriented."" On 02/01/12 at 7:45 p.m., a registered nurse, Employee #31, obtained a telephone order from the treating physician for intravenous (IV) fluids. Normal saline IV at 100 cc/hr for 24 hours was ordered, along with an order to obtain a urinalysis with culture and sensitivity, a complete blood count (CBC) and a comprehensive metabolic panel (CMP). Review of the medical record found no nursing note authored by Employee #31 documenting any assessment of the resident's medical condition which prompted the call to the treating physician. Furthermore, the medical record contained no nursing notes or any other evidence nursing staff had started the ordered IV or obtained the ordered blood work. The medical record contained no further nursing notes until 1:18 p.m. on 02/02/12. This note, authored by licensed practical nurse (LPN) #1, contained no assessment of the resident's condition beyond ""Alert, no distress noted, [DEVICE] intact, head of bed elevated, meds via [DEVICE], iv intact."" There was no assessment of the resident's hydration or respiratory status. There were no nursing notes in the medical record for 02/03/12. On 02/04/12 at 12:08 p.m., an LPN, Employee #12, documented the resident was alert with noted confusion. The resident was noted to be sitting up in geri-chair with no signs or symptoms of pain or distress. The nursing note contained no assessment of the resident's respiratory status or lung sounds. The note did not contain an assessment of the resident's hydration status or any other nursing assessment following the administration of IV fluids. There were no nursing notes in the medical record for 02/05/12. The medical record contained a physician's telephone order, dated 02/06/12 at 7:15 p.m., to transfer the resident to the emergency room for treatment and evaluation. The order was signed by an RN (Employee #31). Employee #31 did not write a nursing note related to the resident's condition which necessitated transfer to the hospital until 1:43 a.m. on 02/07/12. The entry noted the resident had been transferred for increased temperature, congestion, and elevated blood pressure. 3) Laboratory studies Review of the medical record found no evidence the facility had obtained the urinalysis with culture and sensitivity, CBC, and CMP as ordered by the physician at 7:45 p.m. on 02/01/12, prior to the resident being transferred to the emergency roiagnom on [DATE]. Review of the Medication Administration Record [REDACTED]. An interview was conducted with the Director of Nursing (DON), Employee #6, on 02/29/12 at 2:10 p.m. She was asked to provide the results from the laboratory work ordered by the physician on 02/01/12. She was unable to provide evidence the facility had obtained the ordered laboratory services. 4) emergency room Review of the emergency room physician assessment found the following, ""[MEDICAL CONDITIONS] exacerbation. The patient's BNP (Brain Natriuretic Peptide test, indicative of heart failure) is 260, a few weeks ago it was in the 60's. Also on physical exam, there are diffuse crackles/rales and expiratory wheezes. At this point, I would give 40 mg of IV [MEDICATION NAME] (a diuretic)..."". Resident #73 was admitted to the hospital with [REDACTED]. The resident remained hospitalized as of the 03/01/12 exit from the facility. ========== b) Resident #60 Review of the medical record found a physician's orders [REDACTED]. An interview with the Director of Nursing (DON), Employee #6, on 02/29/12 at 3:40 p.m., elicited that ""free water"" meant plain water. Resident #60's room was entered at 3:41 p.m. Observation revealed a pitcher of ice water was present on her bedside table. The resident was alert and oriented. She was asked if she was allowed to have water. The resident responded, ""I can have all the water I want."" The facility provided no evidence the resident or staff members were educated concerning the physician's orders [REDACTED]. Further review of the medical record found that the physician's orders [REDACTED]. .",2015-07-01
10077,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-03-01,323,E,1,0,0TSC11,". Based on medical record review, observation, and staff interview, it was found the facility failed to ensure the resident environment remained as free of accident hazards as possible. An LPN (licensed practical nurse), Employee # 75, was observed wearing long, dark painted fingernails with decorations that extended approximately one (1) inch beyond the fingertips. She also was wearing multiple rings on each hand. This practice constituted the potential for injury to residents when doing care. A stocked, unlocked treatment cart was left unsupervised in the hallway. Medicated ointments and dressing and treatment supplies on this cart were left unsupervised and accessible to residents who were in close proximity. Residents were observed near and around the nursing station. No staff members were present at the nursing station which was accessed by swinging doors. On the counters of the nursing station were several medications as well as a local anti-infective antiseptic. Each item present on the counter had the potential for harm to any resident who accessed them. These practices had the potential to affect more than an isolated number of residents. Facility census: 71. Findings include: a) Employee # 75 During observations in the 300 hallway, on 02/28/12, at approximately 9:45 a.m., this LPN was observed preparing medications for a resident. Observation revealed the nurse's fingernails were long, approximately one (1) inch beyond the fingertips. The nails were painted a dark color with decorations. It was also observed the nurse was wearing multiple rings on each hand. During a brief interview with the nurse, it was revealed nurses did their own treatments on residents on Tuesday, Thursday, Saturday and Sunday. During an interview with the director of nursing (Employee #06), on 02/29/12, at 10:30 a.m., it was agreed wearing long fingernails and multiple rings created a potential for injury to residents during care. . . b) Treatment cart Random observations of the resident environment, on 02/29/12 at 11:30 a.m., noted a treatment cart located against the outside wall of the nursing station. The cart was not visible to staff members seated at the nursing station. The location of the cart prevented staff from viewing residents seated in wheelchairs should they approach the treatment cart. A closer inspection of the treatment cart noted an opened padlock at the corner of the first drawer. The drawers opened freely and contained medicated ointments and other dressing and treatment supplies that had the potential for harm should a resident obtain access to them. The unlocked, stocked treatment cart was brought to the attention of corporate nurse, Employee #81, who agreed the cart should have been locked. c) Nursing station During random observations of the resident environment, on 03/01/12 at 10:40 a.m., no staff members were present at the nursing station. The nursing station was accessed via two (2) waist-high swinging doors. Residents were observed near and around the nursing station. On the counter of the nursing station was a 10 oz bottle of cherry flavored Magnesium Citrate, a bottle of Hydrogen Peroxide, a bottle of B complex with vitamin C containing 130 caplets, and a bottle of antacid tablets. Any of the items present on the counter of the nursing station had the potential for harm to any resident who accessed them. The administrator approached the nursing station and was immediately notified of the potentially hazardous items sitting unattended on the counter of the nursing station. He instructed a staff member to secure the items. .",2015-07-01
10078,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-03-01,441,F,1,0,0TSC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, review of Center for Disease Control (CDC) and World Health Organization (WHO) guidelines, and review of cleaning products, it was determined the facility failed to ensure an effective infection prevention and control program to maintain a safe, sanitary environment to help prevent the development and transmission of infections. This practice had the potential to affect all facility residents. Facility census: 71. Findings include: a) Employee #75 During observations in the 300 hallway, on 02/28/12, at approximately 9:45 a.m., the licensed practical nurse (LPN) was observed preparing medications for a resident. Observation revealed the nurse's fingernails were long, approximately one (1) inch beyond the fingertips. The nails were painted a dark color with decorations. It was also observed the nurse was wearing multiple rings on each hand. During a brief interview with the nurse, it was revealed nurses did their own treatments on residents on Tuesday, Thursday, Saturday and Sunday. Following the medication administration to the resident, this nurse applied sanitizing solution and rubbed her hands together but did not clean under the fingernails or under the rings. Review of literature from the WHO, dated 2009, revealed several studies have shown that skin underneath rings is more heavily colonized with infectious organisms than comparable areas of skin on fingers without rings. The recommendation of WHO is to strongly discourage the wearing of rings or other jewelry during health care. According to CDC recommendations, published 10/26/02, artificial nails are noted to contribute to transmission of healthcare-associated infections. Health care workers who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than are those who have natural nails, both before and after hand washing. The studies referenced in the CDC recommendations provide evidence that wearing artificial nails poses an infection control hazard. During an interview with Employee #6, the director of nursing (DON), on 02/29/12 at 10:30 a.m., it was agreed wearing long fingernails and multiple rings while performing direct care to residents created the potential for transmission of bacteria and microorganisms. This was particularly an issue when there was poor and ineffective hand cleaning. It was agreed this could contribute to the spread of illness. b) Employee #31 During an interview on the 400 hall, with Employee #31, a registered nurse, on 02/28/12 at 10:00 a.m., the nurse was preparing medications for residents. The nurse ran her hands through her hair, which was shoulder length and unrestrained. Observation revealed the nurse failed to cleanse her hands after running her hands continuously through her hair to move it back out of her face and eyes. On 02/29/12 at 10:30 a.m., while interviewing the DON, it was agreed the nurse running her hands through her hair and not sanitizing her hands was an infection control issue. c) During observations in the facility, on 03/01/12 at 10:30 a.m., a brown plastic recliner chair was observed in the day room, a common resident area of the facility. Observation revealed the plastic on the right arm of the chair was worn off exposing the fabric on the arm. The condition of the chair rendered it unable to be effectively cleaned and sanitized to prevent the transmission of pathogenic microorganisms within the facility. At 10:30 a.m. on 03/01/12, during an interview with the administrator, it was agreed the arm of this chair could not be cleaned and sanitized effectively. d) Employee #54 On 02/29/12 at 8:00 a.m., a tracheostomy care demonstration, for a nursing in-service, was conducted by an RN, Employee #54. The in-service demonstration was conducted on Resident #44 who had a tracheostomy. During the demonstration of the procedure, Employee #54's unrestrained hair hung over the sterile field. This practice had the potential to contaminate the sterile field and contribute to infection in the resident's tracheostomy. During an interview, conducted with the DON, on 02/29/12 at 10:30 a.m., it was agreed the nurse should have restrained her hair prior to doing a sterile procedure. . . e) A tour of the facility, conducted on 02/27/12 at 4:00 p.m., noted isolation carts sitting outside three (3) resident rooms. At 10:45 a.m. on 03/01/12, registered nurse (RN), Employee #54, provided a list of residents on contact isolation due to a Clostridium difficile (C. diff) infection. Review of the list found Residents #37, #60, and #70 were identified as having [DIAGNOSES REDACTED]. An interview with the environmental services director, Employee #45, on 03/01/12 at 9:15 a.m., revealed the facility utilized a bleach solution to sanitize bedside tables,commodes, and other above-the-floor surfaces. Employee #45 stated the facility used a different cleanser for the floors in the rooms of the residents who were on contact isolation related to the [DIAGNOSES REDACTED] infections. Employee #45 was asked to provide the manufacturer's information regarding for which organisms the cleanser was effective. The administrator, Employee #39, provided the manufacturer's information at 1:15 p.m. on 03/01/12. The manufacturer's information did not list [DIAGNOSES REDACTED] as one of the organisms for which the cleanser was effective. Employee #39 agreed the cleanser used for the floors of the contact isolation rooms was not effective against Clostridium difficile spores. Use of a cleanser for the floors which was ineffective against Clostridium difficile spores placed all residents at risk of infection from the potential spread of the spores. .",2015-07-01
10079,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-03-01,492,F,1,0,0TSC11,". Based on review of the staffing worksheet completed by the facility for the pay period 02/12/12 through 02/25/12, and staff interview, it was determined the facility failed to operate in compliance with state regulations by failing to maintain a daily staffing ratio at the State required minimum of 2.25 nursing hours per resident. The staffing ratio on Sunday 02/12/12 was 1.89 nursing hours per resident. This practice had the potential to affect the care and well-being of all residents who resided in this facility. Facility census: 71. Findings include: a) During the course of the investigation, the facility was requested to complete a staffing worksheet which showed the nursing hours per resident for the pay period of 02/12/12 to 02/25/12. Review of the completed staffing worksheet revealed the facility staff-to-resident ratio fell below the state required minimum on 02/12/12. The staff-to resident ratio on that day was 1.89 hours. According to the State nursing home licensure rule 64-13-8.14a., the minimum hours per resident per day is 2.25 hours. During an interview with the scheduling manager, Employee #78, on 03/01/12 at 9:15 a.m., it was confirmed the facility staffing dropped below the required staffing ratio on 02/12/12. Employee #78 explained the facility utilized agency staffing services and overtime for facility staff when their nursing hours per resident dropped below their desired hours. Employee #78 said the facility was unable to bring the ratio up to desired levels on that day due to call offs and no availability of agency staff. .",2015-07-01
10080,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-03-01,502,D,1,0,0TSC11,". Based on medical record review and staff interview, the facility failed to obtain physician ordered laboratory services for one (1) of nine (9) sampled residents. A urinalysis with culture and sensitivity, a complete blood count (CBC), and a comprehensive metabolic panel was not obtained for the resident. Resident identifier: #73. Facility census: 71. Findings include: a) Resident #73 Review of the medical record found a physician's telephone order, written at 7:45 p.m. on 02/01/12, to obtain a urinalysis with culture and sensitivity, a complete blood count (CBC) and a comprehensive metabolic panel (CMP) in the morning. Review of the Medication Administration Record [REDACTED]. An interview was conducted with the director of nursing (DON), Employee #6, on 02/29/12 at 2:10 p.m. She was asked to provide the results from the laboratory work ordered by the physician on 02/01/12. She was unable to provide evidence the facility obtained the ordered laboratory services. .",2015-07-01
10081,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-04-17,514,E,1,0,0TSC12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on treatment administration record (TAR) review, resident interview, and staff interview, the facility failed to ensure the medical records for four (4) of nine (9) residents on the sample were accurate. Four (4) residents had physicians' orders for scheduled treatments that were not recorded on the individual's TAR. Resident identifiers: #34, #17, #40, and #48. Facility census: 68. Findings include: a) Resident #34 Resident #34, an [AGE] year-old female, came to the facility on [DATE]. She had a physician's orders [REDACTED]. The physician had ordered the ostomy changed every three (3) days and as needed. The treatment administration record indicated the resident's ostomy appliance had not been changed on 04/07/12. b) Resident #17 Resident #17, a [AGE] year-old female, came to the facility on [DATE]. The skin integrity report revealed she had a stage II pressure ulcer to her right heel. The treatment administration record revealed a physician's orders [REDACTED]. The treatment administration record showed the facility had not completed this treatment on 04/05/12 on the 11:00 p.m. - 7:00 a.m. shift, as well as on the 7:00 a.m. - 3:00 p.m. shift. On 04/12/12, the treatment administration record indicated the treatment to the right heel had not been completed on the 3:00 p.m. - 11:00 p.m. shift. On 04/15/12, there was no evidence the treatment had been completed on the 11:00 p.m. - 7:00 a.m. shift or the 3:00 p.m.-11:00 p.m. shift. c) Resident #40 Resident #40, a [AGE] year old female, came to the facility on [DATE]. She had a current [DIAGNOSES REDACTED]. The treatment administration record revealed a physician's orders [REDACTED]. Apply [MEDICATION NAME] lotion to coccyx every shift. The treatment administration record revealed the facility did not complete the treatment on 04/05/12 during the 11:00 p.m. - 7:00 a.m. shift as well as the 7:00 a.m. - 3:00 p.m. shift. A second physician's orders [REDACTED]. There was no evidence the treatment had been completed on 04/05/12 during the 11:00 p.m. -7:00 a.m. shift. d) Resident #48 Resident #48, a [AGE] year-old female, who came to the facility on [DATE], had a physician's orders [REDACTED]. The skin integrity report revealed the resident had a stage II pressure ulcer to the right buttock. The treatment administration record did not reflect the treatment had been completed on 04/09/11 during the 7:00 a.m. - 3:00 p.m. shift or on 04/13/11 during the 3:00 p.m. - 11:00 p.m. shift. The resident also had an order for [REDACTED]. On 04/17/12, at approximately 2:00 p.m., Employee #31 (licensed practical nurse) indicated she had completed treatments/wound care at the facility Monday through Friday. She said the nurses were responsible for treatments on their residents during the weekend. She reviewed the treatment administration records for the above residents and said the nursing staff should have circled their initials if they were unable to provide a treatment as well as documented on the treatment sheet the reason they were unable to provide the treatment. On 04/17/12, at approximately 2:30 p.m., the director of nursing (DON) (Employee #7) indicated she had contacted the agency nursing staff utilized by the facility because she had concerns about their documentation. She indicated the facility had discussed nursing documentation during the 04/06/12 quality assurance meeting.",2015-07-01
10342,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-01-17,309,D,1,0,9VUN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, review of a residents' hospital discharge summaries, and review of the facility's pharmacy services policies and procedures, it was determined the facility failed to provide the necessary care to maintain the highest practicable physical well-being in accordance with physician orders [REDACTED]. This resident, who had [MEDICAL CONDITION] (MS), was admitted on [DATE], with a physician's orders [REDACTED]. The resident did not receive a dose of this medication until 12/14/11, due to the pharmacy's inability to supply the medication. Additionally, there were three (3) additional missed doses when the facility ran out of the original two (2) week supply from the pharmacy. There also was no evidence the resident's attending physician was notified of the delay in the resident's treatment, or the additional missed doses. Resident identifier: #72. Facility census: 71. Findings include: a) Resident #72 This resident was admitted to the facility on [DATE]. The resident was admitted from the hospital, where this [AGE] year-old had been treated for [REDACTED]. Medical record review revealed the resident's admission orders [REDACTED]. This medication was for treatment of [REDACTED]. During a review of the Medication Administration Record [REDACTED]. The start of the treatment was delayed due to the pharmacy's inability to supply the medication. A review of the December 2011 and January 2012 MARs revealed there was another delay of three (3) doses of Interferon beta, when the facility ran out of the initial two (2) week supply which had been provided by the pharmacy. Interviews were conducted with three (3) licensed nurses (LPNs), Employees #01, #08, and #81, from 11:05 a.m. to 11:20 a.m. on 01/17/12, These LPNs stated they had provided care and medications for this resident. During the interview, the LPNs stated the facility could not get the Interferon from the pharmacy. During an interview with a regional nurse (Employee #91), on 01/17/12 at 12:15 p.m., Employee #91 stated the facility's pharmacy did not have Interferon beta in stock when this resident was admitted to the facility. The regional nurse indicated the facility eventually received a two (2) week supply, and when that was gone, there was another omission of three (3) doses before it became available again. Review of the facility's policy ""7.0 Medication Shortages / Drugs Not Available, process #3 3.3"" indicated if an emergency delivery was unavailable, a licensed nurse was to contact the attending physician to obtain orders or instructions. There was no evidence this was done. Item 5.1 of the policy, regarding when a missed dose was unavoidable, stated the staff was to document missed doses on the MAR, with an explanation in the nurses' notes. Review of the hospital discharge summary revealed documentation which stated, ""If there are any additional questions, our staff is very familiar with this patient and we can help in any way possible."" The discharge summary also provided the name and telephone numbers of the attending physician at the hospital, the nursing unit where the resident was treated, and an invitation to contact the hospital social worker . The discharge summary also stated, ""We really want the patient to succeed and are wishing her the best."" During a review of progress notes, no evidence was found indicating the attending physician had been notified of the problem with getting the ordered medication for the resident. Further interview with the regional nurse (Employee #91), on 01/17/12 at 12:15 p.m., information was requested as evidence the attending physician was notified of the delay in treatment. No further information was provided. .",2015-05-01
10343,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-01-17,425,D,1,0,9VUN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and review of the hospital discharge summary, it was determined the facility failed to provide routine drugs in a timely manner for one (1) of eight (8) sampled residents. Resident #72 was admitted to the facility on [DATE], from the hospital, where she had been treated for [REDACTED]. Upon admission, the resident had a physician's orders [REDACTED]. The resident did not receive a dose of this medication until 12/14/11, due to the pharmacy's inability to supply the medication. Additionally, there were three (3) additional missed doses when the facility ran out of the original two (2) week supply from the pharmacy. Resident identifier: #72. Facility census: 71. Findings include: a) Resident #72 This resident was admitted to the facility on [DATE]. The resident was admitted from the hospital, where this [AGE] year-old had been treated for [REDACTED]. Medical record review revealed the resident's admission orders [REDACTED]. This medication was for treatment of [REDACTED]. During a review of the medication administration records (MAR), for the months of December 2011 and January 2012, it was discovered the resident did not receive a dose of Interferon beta until 12/14/11, although it was ordered on [DATE]. The start of the treatment was delayed due to the pharmacy's inability to supply the medication. The start of the treatment was delayed for several days while the facility's pharmacy attempted to obtain the medication. A review of the December 2011 and January 2012 MARs revealed there was another delay of three (3) doses of Interferon beta, when the facility ran out of the initial two (2) week supply which had been provided by the pharmacy. Interviews were conducted with three (3) licensed nurses (LPNs), Employees #01, #08, and #81, on 01/17/12 from 11:05 a.m. to 11:20 a.m. These LPNs stated they had provided care and medications for this resident. During the interview, the LPNs stated the facility could not get the Interferon from the pharmacy. During an interview with a regional nurse (Employee #91), on 01/17/12 at 12:15 p.m., the nurse stated the facility's pharmacy did not have Interferon beta in stock when this resident was admitted to the facility. The nurse indicated the facility eventually received a two (2) week supply, and when that was gone, there was another omission of three (3) doses before it became available again. The regional nurse confirmed the Interferon had not been provided timely to the resident, or as as ordered by the physician. .",2015-05-01
10548,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-10-18,225,D,1,0,9SJV11,". Based on review of the facility's reportable allegations of abuse / neglect, review of the facility's customer and family concern files, family interview, and staff interview, the facility failed to ensure all allegations of neglect were immediately reported to State officials as required by law. This affected two (2) residents discovered during a review of customer and family concerns reported to the facility in August, September, and October 2010 (month-to-date). Resident identifiers: #10, and #17. Facility census: 69. Findings include: On 10/17/11 at approximately 1:00 p.m., the administrator (Employee #36) provided the facility's records of self-reported allegations of abuse / neglect and customer / family concerns received in August, September, and October 2011 (month-to-date). A review of these documents revealed two (2) customer / family concern forms that contained allegations of neglect. 1. Resident #10 Resident #10's daughter had reported a concern on 10/09/11, which stated the resident's call light was not in reach, her water pitcher was empty, and her oxygen was not turned on but was placed on the resident. The follow-up section of the concern form stated (quoted as written): ""followed up with DON (director of nursing) (name) who spoke with staff and reeducated also family had conversation with DON."" When interviewed on 10/17/11 at approximately 1:30 p.m., Resident #10's daughter stated she had told the facility about several concerns she had regarding her mother's care a few weeks ago. She mentioned coming into the facility on a Sunday and finding her mother's tongue dry and scaly, her water pitcher had a small amount of warm water out of reach, and her oxygen was not connected properly. She stated a nurse came in and viewed the situation and told her she would file a report. The resident's daughter said things had improved, but she did not know if any reports were filed related to her specific concerns. Employee #83 (interim DON) verified that Resident #10 could participate in transferring but could not walk around her room or safely access things (such as water) that were not in her reach. The resident did require the use of oxygen and could use her call light. When interviewed on 10/17/11 at approximately 4:30 p.m., Employee #79 (social worker) acknowledged she had filled out this family concern form. She said she had not reported this to State officials as an allegation of neglect. 2. Resident #17 On 09/06/11, Resident #17 filed a customer concern which stated she felt the facility had not sufficiently addressed her for pain. In the follow-up section of the form was recorded (quoted as written): ""Resident was given pain pill in timely manner but forgot after speaking with resident she was confused about being far away from nurses' desk due to high blood pressure concerns. Resident now on meds to control."" When interviewed on the afternoon of 10/17/11, Employees #83 and #79 both reported the facility had resolved the resident's issues related to pain. Both also confirmed the facility had not treated Resident #17's concern as an allegation of neglect. .",2015-02-01
10823,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-08-26,241,E,1,0,VYDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and policy review, the facility failed to assure direct care staff displayed identification badges while providing care, which would enable residents to identify them. Being able to identify staff members promotes resident feelings of being involved in their care and allows for identification of an alleged perpetrator, should there be an allegation of abuse, neglect, or mistreatment of [REDACTED]. Random observations, beginning at 2:30 a.m. on 08/25/11, found four (4) of nine (9) staff members on duty did not display identification badges. Two (2) of these four (4) individuals who were not wearing identification badges worked for a temporary staffing agency and were not regular employees of the facility. This deficient practice had the potential to affect more than an isolated number of residents. Employee identifiers: #40, #43, #85, and #81. Facility census: 69. Findings include: a) Employees #40, #43, #85, and #81 1. Random observations of the resident environment, on 08/25/11 at 2:30 a.m., noted four (4) of the nine (9) direct care staff members on duty were not wearing identification badges. Interviews with these four (4) individuals elicited that two (2) of them were nursing assistants (Employees #40 and #43) and two (2) of them were nurses who worked for a temporary staffing agency (Employees #81 and #85). After inquiry concerning their lack of identification badges, all staff members subsequently produced badges from their cars, pockets, and purses. - 2. The facility policy titled ""2.22 Identification Badges"" was reviewed at 12:15 p.m. on 08/26/11. The section titled ""Policy"" stated: ""All Genesis employees are required to wear an identification badge while on duty."" The section titled ""Purpose"" stated: ""To promote safety and well being of patients, residents, employees, and visitors."" The section titled ""Process"" stated: ""1. Identification badges are to be worn while on duty using a breakaway lanyard or clip on pins with name clearly visible to others."" - 3. An interview with the administrator, at 12:15 p.m. on 08/26/11, confirmed that all employees should wear identification badges when working. .",2014-12-01
10824,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-08-26,309,D,1,0,VYDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, medical record review, and staff interview, the facility failed to assure one (1) of six (6) residents received appropriate care and services when experiencing respiratory distress. Resident #65 was observed, at 3:00 a.m. on 08/25/11, to have signs of respiratory distress and reported having trouble breathing. An oxygen concentrator was available at bedside in her room, but no supplemental oxygen was being delivered. The nurse on duty - a licensed practical nurse (LPN) whose services were obtained by the facility through a temporary staffing agency - was not aware of a standing order to apply oxygen for shortness of breath. When this order was identified by the surveyor and conveyed to the LPN, she applied supplemental oxygen to the resident, after which the resident reported some relief. Resident identifier: #65. Facility census: 69. Findings include: a) Resident #65 During random observations conducted at 3:00 a.m. on 08/25/11, Resident #65 was noted to by lying in bed on her back. The resident appeared to be struggling for breath, as evidenced by the use of accessory muscles and the presence of audible expiratory wheezes. It was noted that an oxygen concentrator was present at the bedside, but no oxygen had been applied to the resident. The resident stated she was having trouble breathing. When asked why she wasn't wearing oxygen, she stated the nurse told her the ambulance would give her oxygen. Employee #81 (an agency LPN), when interviewed related to the resident not being provided oxygen to assist her breathing, stated she was sending Resident #65 out to the hospital. When asked why no oxygen was applied to the resident, Employee #81 stated she had called the physician to report the resident experiencing shortness of breath. She stated the physician asked what the resident's 02 sat (oxygen saturation) was, and she relayed that it was 95% on room air. She stated the physician did not order oxygen, and the resident did not have an order for [REDACTED]. Immediate review of the resident's medical record found a document entitled ""Protocol for PRN (as needed) Medications"" at the back of her physician's orders [REDACTED]."" The order also required nursing staff to assess and document the resident's vital signs and respiratory sounds. This order was pointed out to another LPN (Employee #41). This was relayed to Employee #81, who applied oxygen via nasal cannula at 2 L/min at 3:16 a.m.. A reassessment of the resident's oxygen saturation found that it had returned to 95% after five (5) minutes. The resident stated the oxygen helped. The ambulance arrived at 3:20 a.m. to transport the resident to the hospital. .",2014-12-01
10825,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-08-26,323,E,1,0,VYDK11,". Based on observation, medical record review, staff interview, and review of facility documents, the facility failed to assure physician's orders were followed to prevent injuries from falls from the bed for four (4) of six (6) sampled residents. Staff failed to assure physician-ordered safety mats were at bedside and the beds were maintained in the lowest position when occupied by these residents. Resident identifiers: #65, #67, #22, and #2. Facility census: 69. Findings include: a) Resident #65 Random observation of Resident #67's room, at 3:00 a.m. on 08/25/11, noted two (2) safety mats were folded and placed beside the wardrobe in the resident's room. No mats on the floor on either side of the resident's bed to cushion her should she roll or fall from the bed. The resident was noted to be experiencing respiratory distress at 3:00 a.m. on 08/25/11. The ambulance arrived at 3:20 a.m. on 08/25/11 to transport the resident to an acute care facility. During transfer by the emergency medical technicians (EMTs), the resident stated, ""Now you watch out for my leg. I hurt it when I fell out of bed."" The resident was noted to be gesturing toward her left leg. Review of the medical record found a current order for a low bed with safety mats to be utilized bilaterally. An interview with a nursing assistant (Employee #43), at 3:40 a.m., revealed the safety mats had not been placed by the resident's bed due to the aide forgetting to put them there. Employee #43 stated she assisted the resident to bed between 9:00 p.m. and 9:30 p.m. and just forgot to put the mats down. Review of facility documents related to falls found that Resident #65 sustained falls from her bed on 07/10/11 (with a bruise and hematoma to her left knee area) and a fall on 07/16/11 with no apparent injuries. -- b) Resident #67 Random observations, conducted on 08/25/11 at 3:50 a.m., noted a nursing assistant (Employee #78) exiting Resident #67's room carrying linen in a clear trash bag. Resident #67's bed had been left in a high position with safety mats on either side of the resident's bed. When the aide returned, she was asked what position the bed should be in when safety mats were present on the floor. Employee #78 stated that the bed should be all the way to the floor. The resident's bed was then lowered into the proper low position. Review of the medical record found a 07/28/11 physician's order for the resident to have a low bed with mats. -- c) Resident #22 Random observation of the resident sleeping environment, on 08/25/11 at 3:50 a.m., noted Resident #22's bed was in a high position with safety mats placed on each side of her bed. The registered nurse on duty (RN - Employee #85) agreed the bed should be in a low position, and she then lowered the bed. Review of the medical record found a 07/26/11 order for the resident to have a low bed and mats for fall precautions. -- d) Resident #2 Random observations, at 3:30 a.m. on 08/15/11, noted Resident #2 had a safety mat on the floor of the left side of her bed. A bedside table was positioned on the right side of her bed with no safety mat. The bedside table was placed such that the resident would strike the base of the bedside table should she roll or fall from the right side of the bed. An interview with a nursing assistant (Employee #40), following the observation, confirmed that a safety mat should be on the floor on the right side of the resident's bed. Employee #40 repositioned the bedside table and placed the mat on the floor. Review of the medical record found the resident had a physician's order for a low bed with bilateral fall mats due to high fall risk as of 11/22/09.",2014-12-01
11069,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-05-04,280,D,1,0,4R4011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to revise an interdisciplinary care plan after a minimum data set (MDS) assessment revealed Resident #40 had not had a bowel movement for at least seven (7) days. There was no evidence this resident's constipation was addressed after it was identified through the assessment process, to assure interventions were implemented to alleviate this resident's constipation. This resident experienced a total of twelve (12) days without having a bowel movement and no interventions were initiated. This was found to be true for one (1) of six (6) sampled residents. Resident identifier: #40. Facility census: 73. Findings include: a) Resident #40 Review of Resident #40's medical record revealed a Medicare 14-Day MDS, with an assessment reference date (ARD) of 04/30/11, in which the assessor encoded ""9"" in section H0400 to indicated the resident's bowel continence was not rated because either the resident had an ostomy or the resident did not have a bowel movement for the entire 7-day assessment reference period. Further record review revealed the resident did have an ostomy (a gastrostomy, but not a [MEDICAL CONDITION]). The record also indicated her last recorded bowel movement occurred on 04/22/11. A review of this resident's April 2011 activities of daily living (ADL) flow record revealed this resident had an extra large BM and a small BM on 04/22/11. Further review of the ADL flow sheet for April 2011 revealed she did not have another BM during the remainder of the month (a total of eight (8) days). The ADL flow sheet for May 2011, when reviewed, revealed this resident had not had a BM the first four (4) days of that month. This was a total of twelve (12) consecutive days with no BM. The medication administration records (MARs) for both April and May 2011, when reviewed, found no evidence this resident had received a laxative or any type of medication for constipation at any time during these two (2) months. The nursing notes for Resident #40 contained no mention of any issues with constipation or any acknowledgement that she had not been having BMs. During an interview with a registered nurse assessment coordinator (RNAC - Employee #73) on 05/04/11 at 10:50 a.m., she verified she completed the MDS for Resident #40. She stated she encoded this MDS item as ""9"", because there was no evidence this resident had a BM for the 7-day assessment reference period. When questioned as to what actions she took after identifying the resident had had no BM during the 7-day assessment reference period, she stated she always tells the nurse on the hall when a resident has not had a BM, but she could not remember which nurse she told. She confirmed she had not documented having to told the nurse this anywhere, and she verified that the last BM this resident had recorded in her medical record (as of this date - 05/04/11) was on 04/22/11. There was no evidence this issue had been addressed in the resident's care plan or that any interventions had been initiated after the RNAC identified the resident was experiencing problems with constipation. .",2014-09-01
11070,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-05-04,309,G,1,0,4R4011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and observation, the facility failed to provide care and services necessary to maintain a resident's highest practicable physical well-being, including adequate assessment, monitoring, and/or prompt intervention in response to the identification of abnormal findings on a resident assessment instrument. On 04/22/11, Resident #40 was noted to have had two (2) bowel movements; however, staff failed to identify that Resident #40 did not have a bowel movement for three (3) consecutive days thereafter, and failed to implement to facility's Bowel Protocol, which indicated staff was to administer milk of magnesia (MOM) if a resident has had no BM after three (3) days. The facility's registered nurse assessment coordinator (RNAC) later identified, on a resident assessment instrument, that Resident #40 had not had a BM during a 7-day assessment reference period ending on 04/30/11. (This was unusual for her, as the resident's bowel elimination pattern had previously identified she had BMs every other day.) However, staff did not intervene by collecting information about her physical health status and/or by initiating the physician's standing order for constipation at that time. On 05/04/11, after the nurse surveyor questioned staff about the resident's lack of BMs for a period of twelve (12) days, staff administered the first step of the facility's Bowel Protocol, a 30 cc dose of MOM (which was to be given after a resident had no BM for three (3) days), without completing a physical assessment of the resident. When a physical assessment of the resident was completed at the nurse surveyor's request, the resident moaned, stating, ""My stomach hurts."" Resident #40 continued to moan and had a look of discomfort on her face. Staff later administered an enema, after which the resident expelled an extra large BM. The deficient practice resulted in actual harm to one (1) of six (6) sampled residents and has the potential to result in harm to more than an isolated number of the facility's residents. Facility census: 73. Findings include: a) Resident #40 1. Record review, on 05/04/11, revealed Resident #40, who had been admitted to the facility on [DATE], had a bowel retraining assessment dated [DATE], which identified her usual bowel elimination pattern as having a BM every other day. This assessment also revealed she did not have a history of constipation. Review of Resident #40's interdisciplinary care plan, dated 04/25/11, found this resident was identified as being at risk for gastrointestinal symptoms or complications related to the use of a gastrostomy tube ([DEVICE]). The interventions associated with this problem included: ""Assess for and report signs and symptoms of nausea / vomiting, abdominal distention, decrease in bowel movements, decrease in bowel sounds, and abdominal pain."" Another intervention stated: ""Monitor and record bowel movements."" These were the only interventions in the care plan related to this resident's bowel elimination. Review of Resident #40's medical record revealed a Medicare 14-Day MDS, with an assessment reference date (ARD) of 04/30/11, in which the assessor encoded ""9"" in section H0400 to indicated the resident's bowel continence was not rated, because either the resident had an ostomy or the resident did not have a BM for the entire 7-day assessment reference period. Further record review revealed the resident did have an ostomy (a gastrostomy, not a [MEDICAL CONDITION] or other bowel diversion). The record also indicated her last recorded BM occurred on 04/22/11. A review of this resident's April 2011 activities of daily living (ADL) flow record revealed this resident had an extra large BM and a small BM on 04/22/11. Further review of the ADL flow sheet for April 2011 revealed she did not have another BM during the remainder of the month - a total of eight (8) days. The ADL flow sheet for May 2011, when reviewed, revealed this resident had not had a BM the first four (4) days of that month. This was a total of twelve (12) consecutive days with no bowel movement. The medication administration records (MARs) for both April and May 2011, when reviewed, found no evidence this resident had received a laxative or any type of medication for constipation at any time during these two (2) months. The nursing notes for Resident #40 contained no mention of any issues with constipation or any acknowledgement that she had not been having BMs. -- 2. During an interview with the RNAC (Employee #73) on 05/04/11 at 10:50 a.m., she verified she completed the above-mentioned MDS for Resident #40. She stated she encoded this MDS item as ""9"", because there was no evidence this resident had a BM for the 7-day assessment reference period. When questioned as to what actions she took after identifying the resident had had no BM during the 7-day assessment reference period, she stated she always tells the nurse on the hall when a resident has not had a BM, but she could not remember which nurse she told. She confirmed she had not documented having to told the nurse this anywhere, and she verified that the last BM this resident had recorded in her medical record (as of this date - 05/04/11) was on 04/22/11. -- 3. During an interview on the morning of 05/04/11, the nurse assigned to care for Resident #40 (a licensed practical nurse (LPN - Employee #3)) was questioned about the facility's process for identifying residents who were experiencing constipation and how the nurses were made aware of the need to further assess residents for constipation. She stated the clerk at the desk reviews the books containing the BM records and lets the nurses know if the residents need something, or sometimes the nursing assistants let them know. She said the nurses used to check the books, but they don't any more. When questioned about Resident #40, Employee #3 stated she was not aware the resident had not had a BM, because no one had said anything to her. When asked about the facility's bowel protocol, Employee #3 stated that, if a resident has not had a BM in three (3) days, they give 30 cc of MOM. If the resident does not have a BM within eight (8) hours after receiving the MOM, they give the resident a suppository ([MEDICATION NAME] rectal suppository). If the resident does not have a BM within eight (8) more hours, they notify the doctor. -- 4. An interview was conducted with the RN unit manager (Employee #83) at 11:45 a.m. on 05/04/11. She stated that, if constipation had been identified for Resident #40, the interventions should be recorded on the MAR. She stated the nursing assistants record the residents' BMs on the ADL flow sheets, then they report to the nurse or the unit manager. She stated the MDS nurses also bring this to their attention. When asked if anyone else monitors this, she said not that she is aware of. She stated the facility's Bowel Protocol is in front of every MAR book. She stated if this protocol is initiated, the nurses pass it on during report at shift change. -- 5. A nurse administered MOM to Resident #40 at 3:15 p.m. on 05/04/11. However, review of the resident's medical record found no evidence that a physical assessment had been completed on the resident. Employee #83 was asked to complete a physical assessment of Resident #40 with this nurse surveyor present. The resident was in bed at that time. Employee #83 told the resident what she was going to do. The nurse listened to her bowels and reported that bowel sounds were present. As she touched the resident's abdomen with her stethoscope, the resident started moaning. The nurse then felt her stomach, and the resident was moaning, stating, ""My stomach hurts."" Resident #40 continued to moan and had a look of discomfort on her face. Employee #83 asked Resident #40 if she had a BM today, and the resident answered, ""No."" Employee #83 then asked if her bowels moved yesterday, and she again said, ""No."" The resident told the nurse, ""I thought they were going to move, but they didn't."" -- 6. The director of nursing (DON - Employee #76) was notified, on 05/04/11 at 3:30 p.m., of these observations, including the resident's moaning and complaints of stomach pain when assessed. The DON was also made aware of the resident having had no BMs for the preceding twelve (12) days. She responded that she reviewed the resident's medical record and saw that she had complained of stomach pain when she came in. This nurse surveyor told the DON that, according to the resident's MAR, Resident #40 had received a dose of MOM. However, the facility's Bowel Protocol indicated that MOM was to be given when a resident has had no BM in three (3) days, and Resident #40 had had no BM in twelve (12) days. The nurse surveyor asked the DON to have someone notify the physician of Resident #40's condition. The DON returned at 4:00 p.m. and informed this nurse surveyor that the nurses gave Resident #40 an enema, and she had extra large results. .",2014-09-01
11071,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-05-04,322,D,1,0,4R4011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to assure staff implemented appropriate measures to prevent complications from occurring for residents with gastrostomy tubes ([DEVICE]s). Two (2) of three (3) residents with [DEVICE]s were observed to not receive appropriate services to prevent complications from occurring. Observation found Resident #40, who had [DEVICE], lying with her bed in a flat position (head of bed not elevated) fifteen (15) minutes after her enteral feeding had ended. Review of her physician's orders [REDACTED]. Additionally, this resident, who was not to receive anything by mouth, was observed with a glass of chocolate milk, and the facility had not been monitoring her bowel elimination as directed in her care plan to address her new [DEVICE]. Resident #7, who also had a [DEVICE], was also observed to be in a flat position without her head elevated while her feeding was infusing, placing her at risk for aspiration. Resident identifiers: #40 and #7. Facility census: 73. Findings include: a) Resident #40 1. During an observation of Resident #40 on 05/03/11 at 11:15 a.m., she was sitting up in her wheelchair beside of her bed, and her [DEVICE] feeding of [MEDICATION NAME] 1.2 was infusing at a rate of 60 cc / hour at that time. The resident was again observed at 11:45 a.m., at which time her feeding pump was turned off and she was lying in her low bed with mats on the floor. The head of her bed was flat (not elevated) at the time of this observation. Review of her physician's orders [REDACTED]. - 2. Further review revealed an order, written on 04/20/11, for her status to be NPO (nothing by mouth). She had a [DIAGNOSES REDACTED]. Review of the facility's incident / accident reports found a report, dated 04/22/11, stating this resident had consumed a portion of a meal tray that had been left in her room for another resident. Documentation on the reported noted her NPO status; she was assessed and did not have complications from that occurrence. Observation, on 05/04/11 at 12:15 p.m., found Resident #40 sitting in her wheelchair with a glass of chocolate milk in front of her. This nurse surveyor questioned the nurse on the hall (Employee #73) if this resident was allowed to have that chocolate milk. She verified, by reviewing the physician's orders [REDACTED]. She took it out of the resident's room. - 3. Review of Resident #40's interdisciplinary care plan, dated 04/25/11, found this resident was identified as being at risk for gastrointestinal symptoms or complications related to the use of a gastrostomy tube ([DEVICE]). The interventions associated with this problem included: ""Assess for and report signs and symptoms of nausea / vomiting, abdominal distention, decrease in bowel movements, decrease in bowel sounds, and abdominal pain."" Another intervention stated: ""Monitor and record bowel movements."" Review of Resident #40's medical record revealed a Medicare 14-Day minimum data set (MDS), with an assessment reference date (ARD) of 04/30/11, in which the assessor encoded ""9"" in section H0400 to indicated the resident's bowel continence was not rated, because either the resident had an ostomy or the resident did not have a bowel movement (BM) for the entire 7-day assessment reference period. Further record review revealed the resident did have an ostomy (a gastrostomy, not a [MEDICAL CONDITION] or other bowel diversion). The record also indicated her last recorded BM occurred on 04/22/11. A review of this resident's April 2011 activities of daily living (ADL) flow record revealed this resident had an extra large BM and a small BM on 04/22/11. Further review of the ADL flow sheet for April 2011 revealed she did not have another BM during the remainder of the month - a total of eight (8) days. The ADL flow sheet for May 2011, when reviewed, revealed this resident had not had a BM the first four (4) days of that month. This was a total of twelve (12) consecutive days with no bowel movement (from 04/23/11 to 05/04/11). There was no evidence that any interventions to address constipation had been initiated during this time or that anyone had further assessed the resident's health status and reported the lack of BMs to the resident's physician, as stated in her care plan to prevent complications related to the [DEVICE]. - 4. The registered nurse (RN) unit manager (Employee #83) was notified, on 05/04/11 at 3:10 p.m., of the above findings and concerns with respect to the [DEVICE] feeding, including the resident's positioning not being maintained after she had her feeding as ordered, the resident's NPO status not being maintained, and the failure to monitor BMs as stated in the care plan. -- b) Resident #7 On 05/03/11 at 11:05 a.m., observation found Resident #7 lying flat in the bed with enteral feeding infusing through the resident's [DEVICE]. The head of the bed was not elevated to prevent aspiration. Review of the facility's enteral feeding policy revealed Resident #7 should have been positioned in a semi-Fowler's or high Fowler's position, with the head of the bed elevated to thirty (30) to forty-five (45) degrees during feeding. Review of Resident #7's care plan found a goal related to enteral tube feedings which stated the resident will display no signs and symptoms of aspiration. The care plan also contained the following interventions to be provided by staff: ""Aspiration precautions. Head of bed elevated 30-45 degrees during feeding."" On 05/03/11 at 11:05 a.m., the director of nursing (Employee #76) was immediately notified of this finding. .",2014-09-01
11072,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-05-04,281,E,1,0,4R4011,". Based on observation, staff interview, record review, a review of the facility's policy procedures on medication administration times, and the facilities competency testing, the facility failed to provide services according to their policy and to meet professional standards of clinical practice. This deficient practice had the potential to affect more than an isolated number of residents. Facility census: 73. Findings include: a) The medication pass was observed randomly throughout three (3) days of the complaint investigation. Entrance to the facility was on 05/02/11 at 10:15 a.m. Two medication passes were being performed by two (2) licensed practical nurses at the time of entrance. The medications for the one hundred (100) hall (Employee #74) and three hundred (300) Hall (Employee #69) were scheduled to be given at 9 a.m. During the observation on 05/02/11 the one hundred (100) hall was completed at 11:55 a.m. and the three hundred hall (300) was completed at 11:35 a.m. The medication pass should have been completed by 10:00 a.m. according to the facility's policy and in order to meet the professional standards of clinical practice. Further review of the Medication Administration Record [REDACTED]. This finding was discussed with the director of nursing (employee #76) and the nurse passing the medications (Employee #74) at 1:10 p.m. on 05/02/11. The facility's medication administration times policy and the nursing competency testing was reviewed on 05/03/11. According to the medication administration times policy the medication administration pass may begin sixty (60) minutes before the designated times of administration, but may not exceed sixty (60) minutes after the designated times of administration. On 05/03/11 at 9:40 a.m. the licensed practical nurse for (400) hall was observed just beginning her medication pass. On 05/03/11 at 9:40 a.m. (Employee #3) stated, ""I thought I would start with this hall first."" Review of the facility's medication administration times revealed that the 400 Hall is scheduled to begin at 8:00 a.m. During the observation of the medication pass on 05/04/11 (Employee #48) was passing the medications for the two hundred (200) hall and completed her medication pass at 10:10 a.m. The one hundred (100) hall was completed at 11:00 a.m. by (Employee #74). The RN unit managers were asked by this surveyor how they monitor the nurses on the floor. On 05/04/11 at 9:10 a.m. during an interview with the RN unit manager (Employee #83), she stated, ""I monitor the interactions with the nurses and the residents, I also monitor timeliness of the medication pass."" Employee #83 further stated that she is at the medication cart at least eight (8) times per day. When this surveyor informed Employee #83 the timeliness of the medication passes observed, she proceeded to assist Employee #3 with her medication pass. Employee # 62 was asked the same question related to monitoring the nurses on the floor she stated, ""I try to monitor timeliness of the medication pass."" Observations of the medication pass were discussed on the afternoon of 05/03/11 and again on 05/04/11 with the director of nursing (Employee #76) and the nurses conducting the medication passes (Employee #74), and (Employee #3). .",2014-09-01
11073,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-05-04,282,D,1,0,4R4011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, policy review, and record review, the facility failed to provide care in accordance with a resident's written care plan. During a 3-day complaint investigation, observation found one (1) of three (3) residents who received enteral feedings via a gastrostomy tube ([DEVICE]) lying flat with the head of the bed not elevated in accordance with interventions identified in the resident's care plan intended to prevent aspiration. Resident identifier: #7. Facility census: 73. Findings include: a) Resident #7 On 05/03/11 at 11:05 a.m., observation found Resident #7 lying flat in the bed with enteral feeding infusing through the resident's [DEVICE]. The head of the bed was not elevated to prevent aspiration. Review of the facility's enteral feeding policy revealed Resident #7 should have been positioned in a semi-Fowler's or high Fowler's position, with the head of the bed elevated to thirty (30) to forty-five (45) degrees during feeding. Review of Resident #7's care plan found a goal related to enteral tube feedings which stated the resident will display no signs and symptoms of aspiration. The care plan also contained the following interventions to be provided by staff: ""Aspiration precautions. Head of bed elevated 30-45 degrees during feeding."" On 05/03/11 at 11:05 a.m., the director of nursing (Employee #76) was immediately notified of this finding. .",2014-09-01
11074,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2011-05-04,323,D,1,0,4R4011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and record review, the facility failed to provide an environment that was as free as possible from accident hazards, for two (2) of three (3) residents with gastrostomy tubes ([DEVICE]s) who did not receive care and services to prevent aspiration. Resident identifiers: #7 and #40. Facility census: 73. Findings include: a) Resident #7 On 05/03/11 at 11:05 a.m., observation found Resident #7 lying flat in the bed with enteral feeding infusing through the resident's [DEVICE]. The head of the bed was not elevated to prevent aspiration. Review of the facility's enteral feeding policy revealed Resident #7 should have been positioned in a semi-Fowler's or high Fowler's position, with the head of the bed elevated to thirty (30) to forty-five (45) degrees during feeding. Review of Resident #7's care plan found a goal related to enteral tube feedings which stated the resident will display no signs and symptoms of aspiration. The care plan also contained the following interventions to be provided by staff: ""Aspiration precautions. Head of bed elevated 30-45 degrees during feeding."" On 05/03/11 at 11:05 a.m., the director of nursing (Employee #76) was immediately notified of this finding. -- b) Resident #40 1. During an observation of Resident #40 on 05/03/11 at 11:15 a.m., she was sitting up in her wheelchair beside of her bed, and her [DEVICE] feeding of Jevity 1.2 was infusing at a rate of 60 cc / hour at that time. The resident was again observed at 11:45 a.m., at which time her feeding pump was turned off and she was lying in her low bed with mats on the floor. The head of her bed was flat (not elevated) at the time of this observation. Review of her physician's orders [REDACTED]. - 2. Further review revealed an order, written on 04/20/11, for her status to be NPO (nothing by mouth). She had a [DIAGNOSES REDACTED]. Review of the facility's incident / accident reports found a report, dated 04/22/11, stating this resident had consumed a portion of a meal tray that had been left in her room for another resident. Documentation on the reported noted her NPO status; she was assessed and did not have complications from that occurrence. Observation, on 05/04/11 at 12:15 p.m., found Resident #40 sitting in her wheelchair with a glass of chocolate milk in front of her. This nurse surveyor questioned the nurse on the hall (Employee #73) if this resident was allowed to have that chocolate milk. She verified, by reviewing the physician's orders [REDACTED]. She took it out of the resident's room.",2014-09-01
2814,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-03-28,561,D,1,0,6XMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview and medical record review, the facility failed to ensure a resident was afforded the right to exercise autonomy regarding what the resident felt was an important aspect of her life. The facility failed to provide the opportunity for a resident to receive showers according to their preference and choice. This was true for one (1) of five (5) residents reviewed during a complaint investigation. Resident identifier: #1. Facility census:124. Findings included: a) Resident #1 An interview, on 3/27/19 at 11:00AM, revealed Resident (R#1) was admitted to the facility 08/22/18 for rehabilitation services post hernia repair surgery. The resident said she had a lot of complications and health issues from a hernia repair surgery done in (MONTH) (YEAR). When ask if the Resident felt there was enough staff working in the facility, the resident replied, There is not enough staff . I have only had a few showers since I've been here . The resident stated she had been in and out of the hospital a lot since her hernia repair surgery for [REDACTED].#1 said she has a wound vac on her belly from complications and infection from the hernia surgery . The nurse aid (NA#109) I have today is the best one, she is the one that asks me if I want a shower and makes sure I get one no matter how busy she is. I love taking showers, I feel cleaner. They always do wash me off and make sure I'm clean, but it is not the same as having a shower. I think I just feel dirty because of the wound vac and it makes me feel like I stink. An interview, on 3/28/19 at 10:00AM, revealed Resident (R#1) said she thought she may have told a nurse and another NA she preferred showers over bed baths. R#1 stated NA#109 makes sure I get my showers now. R#1 said, They do wash me off, and I know they keep me clean. I don't know if it's because of the wound vac that makes me think I stink. But I feel like I stink, I want showers. Review of R#1medical records revealed the resident was admitted to the facility on [DATE], for rehabilitation due to complications and generalized weakness from a hernia repair surgery and chronic disease processes. The resident needs extensive assistance with all activities of daily living. Some significant [DIAGNOSES REDACTED]. The resident was transferred and admitted to the hospital multiple times since being admitted to the facility. - R#1 was sent to the hospital and admitted to the hospital on [DATE]; and was discharged back to the facility on [DATE]. - R#1 was sent to the hospital and admitted to the hospital on [DATE]; and was discharged back to the facility on [DATE]. - R#1 was sent to the hospital and admitted to the hospital on [DATE]; and was discharged back to the facility on [DATE]. - R#1 was sent to the hospital and admitted to the hospital on [DATE]; and was discharged back to the facility on [DATE]. - R#1 was sent to the hospital and admitted to the hospital on [DATE]; and was discharged back to the facility on [DATE]. - R#1 was sent to the hospital and admitted to the hospital on [DATE]; and was discharged back to the facility on [DATE]. Review of the facility shower records showed Resident #1 had no showers documented in the months of August, September, October, November, (MONTH) (YEAR). Resident #1 only had one (1) shower in the month of January, on 01/01/19; one (1) shower in the month of February, on 02/01/19; and three (3) showers so far in the month of March, 03/05/19, 03/21/19, and 03/25/19. There are no records for R#1 showing she received any showers anytime in (YEAR) after her original admission on 08/22/18. An interview with Center Nurse Executive (CNE, formerly known as director of nursing), on 03/28/19 at 11:47 AM, confirmed there was no documentation of showers for R#1 other than five (5) showers documented this year in 2019. The CNE confirmed the resident, even though out of the facility hospitalized for [REDACTED].",2020-09-01
2815,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-03-28,725,E,1,0,6XMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review, resident interview, and staff interview, the facility fails to ensure adequate and appropriately deployed staffing to meet the needs of residents; such as answering call lights in a timely manner, more teamwork in handling resident's requests, and a resident receiving showers. This practice had the potential to affect more than a limited number of residents. Facility census: 124. Resident identifier: #1,#2,#4, and #6. Facility census: 124. Findings included: a) Resident Council On 03/25/19 at 3:15 PM, review of resident council minutes dated 12/24/18, revealed in Resident Requests/Concerns, it was noted, . Should be more teamwork between staff in answering lights and handling resident needs. The departmental response form from the nursing department stated, Residents feel that there could be more teamwork with answering call lights and helping meet their needs. The response was to see attached education. The attached sign in sheet for the provided In-service education under Topic & Description stated, Please do not tell resident that you 'are not' their aides, answer lights and work as a team together for the best outcomes for the resident. Instruction stated, By signing below, I acknowledge that the above reeducation did occur and that I fully understand the reeducation including my responsibility to implement the above. Interview with resident council president, on 03/27/19 at 2:00 PM, revealed resident council had discussed in their meetings about call lights not being answered quickly and residents having to wait for assistance or items requested. Resident council president explained that residents have complained that some staff came into their room and turned off the call light without helping them. Residents were told by some staff when they turned off the call light, that they would let the resident's nurse aid that was assigned to them know, that they were not their assigned nurse aid. Resident council president said residents reported that at times they have had to wait as much as thirty (30) minutes to an hour for their call light to be answered. When asked what the facility said they would do about it, the resident council president replied, They said they would have a training. The activities director told us that sometimes there just isn't enough staff working. When asked if residents now still had to wait a long period of time to get their call light answered, the resident council president replied, Yes at times, but it has gotten better. An interview with the Activities Director, on 03/27/19 at 2:30 PM, revealed the Activities Director denied ever telling resident council there wasn't enough staff working. When asked what the facility did do about the situation, the Activities Director replied, An in-service training was given to all nursing staff to work as a team and to promptly answer call lights. A review of resident council minutes with the Center Nurse Executive (CNE, formerly known as director of nursing), on 03/26/19 at 1:35 PM, revealed resident council had complained of nursing staff needing more teamwork in answering lights and handling resident's requests. CNE explained that some aides were not answering call lights timely or responding to resident's requests if they were not assigned to them but would pass on the resident's requests to the assigned nurse aid. When asked who should have had the in-service mentioned in the resident council minutes, the CNE replied, All nursing. There were thirty-one (31) signatures of registered nurses, licensed practical nurses, and nursing aides on the attached sign in sheet for the provided In-service education. The CNE stated there are sixty-six (66) nursing staff working at the facility and confirmed that all nursing staff did not get the reeducation as they should have. b) Concerns/Grievances Review of a grievance dated 03/07/19, at 1:00 PM on 03/26/19, revealed eight (8) different areas of concern identified during Resident #6's care plan meeting with the resident's daughter who was the resident's power of attorney (POA). The last issue identified and addressed concerned the facility being short staffed. This issue of concern was addressed by the CNE by reviewing staffing numbers with the resident's daughter and giving the explanation that staffing in a long-term care facility will not be equal to acute care settings or the private sector settings. c) Reportable Allegations Review of reportable allegations dated 03/13/19, on 03/26/19 at 2:30 PM, revealed allegations of neglect concerning five (5) different residents, that after the facility's investigations were all unsubstantiated. The nurse aide identified in all five (5) incidents no longer works at the facility. This surveyor attempted to interview all five (5) residents identified in the reportable allegations, however none of the five (5) residents were interview able. Some notable issues identified in the allegations was a call light not being answered, turning off a call light without providing the requested washcloth, and the nurse aid turning off the call light while saying she would be back but not returning. d) The facility assessment's staffing plan Review of the facilities assessment revealed the facility's staffing plan to ensure they have enough staffing to meet the needs of the residents at any given time is based on the resident population and their needs for care and support. Licensed nurses providing direct care was designated as follows: - One (1) full time Center Nurse Executive (CNE, formerly known as director of nursing), working day shift. - Registered nurse (RN) or licensed practical nurse (LPN) charge nurse: one (1) for each shift per unit on day shift and one (1) charge nurse on night shift. - Restorative nurse manager Monday through Friday day shift. - ADNU three (3) on day shift with backup plan with duties divided for vacancy factor: 1:21 License nurse ratio on 7:00 AM through 7:00 PM shift and 1:32 ratio nights 7:00 PM to 7:00 AM Direct care staff was designated in the facility staffing plan as: 1:8 ratio on days (total licensed and certified); 1:8 ratio on evenings 3:00 PM to 7:00 PM, and 1:9 ratio from 7:00 PM to 11:00 PM. Nights from 11:00 PM to 7:00 AM a 1:12 ratio. e) Center Nurse Executive interview An interview with the Center Nurse Executive (CNE), on 03/27/19 at 12:39 PM, revealed staffing assignments are arranged and adjusted based on acuity. Information concerning residence care needs, diagnoses, plans of care, and social elements such as residents having behaviors is used as a guide to make assignments and adjust to correct issues when identified. The example the CNE gave was about a recent rearrangement of assignments on the south unit. The CNE said instead of assigning rooms in a row that might have residents with greater needs or acuity going to one NA, she tried to make it more even and fair for a NA by scattering the room assignments so a NA would not have all the residents with a larger number of care needs, that way it would make it a more even workload. The CNE stated the facility was down fifteen (15) nursing staff, and at this time there are three (3) agency nurses and two (2) agency NAs working at the facility. The CNE said all shifts are being covered. It was explained that staff could make supplement staffing bonuses of $200 (two hundred dollars) per shift and can work sixteen (16) hours. The facility can mandate staff to work one time a week and one time on the weekend. These mandates are built into their scheduling calendar. Some staff want to work more than that and any other shifts they pick up is time and a half, and the bonus. They have employees that work double at their request or pick up double shifts. f) Administrator staffing notes On 03/28/19 at 11:00AM interview with the administrator and review of staffing calculation worksheet for 01/26/19 showed 2.34 as the HPPD (Hours per patient per day). Staff posting form shows 388 hours scheduled, but there were two (2) nursing aid (NA) call offs and one (1) nurse call off. The Administrator stated those changes were handwritten on the staffing calculation worksheet as call offs and when call offs occur the total scheduled hours are not recalculated, nor does it reflect if someone is late or works over. The Administrator said it only reflects if a shift was picked up. The Administrator stated the time details that shows the actual in and out punches, show 313.14 hours meaning the actual HPPD is above what was designated on the calculation worksheet, which would equal 2.46. The Administrator said, We will have to look into this we are cheating ourselves. Review of the facility's staffing calculation worksheet for 02/14/19 shows 3.06 hours of direct nursing care per resident per day. Posting form shows 367 scheduled staffing hours, with call off changes handwritten on the staffing calculation worksheet. Plus, the two (2) shifts that were picked up were handwritten on the worksheet. Time detail shows 460 worked hours equaling 3.5 HPPD. On 03/11/19 staff calculation shows 3.49, the posting form shows 3.45 . Time detail is 3.89 HPPD. On 03/13/19 staff calculation shows 3.27, the posting form shows 3.00. Time detail is 3.80. g) Nurse Aid Interviews Interview with nurse aid (NA#41), on 03/26/19 at 3:40 PM, revealed NA worked on the North unit and usually had fourteen (14) residents assigned to her. She stated she did complete her assignments daily. She had completed all her trainings on vita-learn a computer web-based program the facility required. NA#41 said the facility mandated her one day a week and one day on the weekend. NA#22 was able to give examples of what abuse, neglect, changes of condition, that should be reported to a nurse. On 03/26/19 at 3:55 PM, an interview with nursing aid (NA#67), revealed NA#67 was doubling back at the time of the interview. NA#133 walking by heard NA#67 tell this surveyor that she was doubling back, and replied, They're so short staffed here, we work over every mandated day. This surveyor asked, When is the mandated days? NA#133 replied, One day a week, it's a different day for different staff. Then we are expected to work one day on the weekend, they put it on our schedule. Both nursing assistants said that they do training on the website and attendant in-services. Both nursing assistants said they get evaluations every so often on their skills. NA#133 said, Training is not the problem, having enough hands on to help is. They both said they had been instructed to answer any call light they see on and help the residents whether their assigned to them or not. NA#133 said, We are not to go in and turn the light off without first helping the resident. An interview with NA#109 on 03/27/19 at 10:33 AM, revealed the NA usually works on the TCU unit. NA#109 said it was a faster pace unit than the other floors, it can be hectic especially on shower days, when you get a new admission, or when a resident come back from [MEDICAL TREATMENT]. NA#109 stated she always completes her assignments and gives her residents the care they should have. On evenings she has half the floor, about thirteen (13) residents. When asked how often she was asked to work over, she said she's mandated a lot lately. NA#109 said, I want to take care my people. I treat them like they were my mother or my grandmother. I always ask them if they got their showers, they are scheduled to have showers two (2) times a week. When asked if the residents got both showers, NA#109 replied, Mine do, I'm not sure about the others. An interview with nurse assistant (NA#208), on 03/28/19 at 9:10 AM, revealed on that day the NA had nine (9) residents to care and usually has up to nine (9) residents to care for daily. She said it was according to the workload how many residents were assigned to her. NA#208 stated it's not too bad during the day, on evening shift sometimes the workload doubles. Evenings always seem short lately. The most residents the aide said she had in the evenings was sixteen (16). When asked how she handles that many residents the aide said she doesn't take lunch and constantly walks to make her rounds. NA#208 she always completes her required assignments each day and stated all her residents were offered and/or got their showers unless they refused, and that is documented. NA#208 said she is mandated one day a week and one day on the weekend. We follow the care plans the information is on our Kardex what care to provide. Sometimes a nurse will provide the care that a nurse aide does. When the aid was asked if that made the floor short a nurse, NA#208 replied no because there's another nurse also on the schedule to do the nursing. NA#208 said she had her abuse and neglect, resident rights, dementia care training, and other trainings on line that was mandatory to do. NA#208 said if she saw any change in a resident, she would report it to a nurse. Interview with NA#22, on 03/28/19 at 9:30 AM, revealed she had not been at the facility for a very long time, a few weeks. She had completed all for trainings before the facility would allow her on the floor and she knew that they were mandated to work one day a week and one day on the weekend. She said she had not been there long enough to work very much overtime, but if she wanted to work more overtime than the mandated days the facility would let her. The aide said that she would report any changes in a resident's condition to a nurse. NA#22 was able to give examples of what abuse and neglect was and what type of issues should be reported to a nurse. h) Resident #1, Showers An interview, on 3/27/19 at 11:00AM, revealed Resident (R#1) was admitted to the facility 08/22/18 for rehabilitation services. When ask if the Resident felt there was enough staff working in the facility, the resident replied, There is not enough staff because sometimes the nurses have to work as nurse aides (NA) because they do not have enough NAs working. They take too long to answer the call light sometimes thirty minutes or more, and I have only had a few showers since I've been here. If there were more nurse aides, it would be a great place. The resident stated she had been in and out of the hospital a lot for different things, since (MONTH) (YEAR) when she had a hernia repair surgery. R#1 said she has a wound vac on her belly from complications and infection from the hernia surgery. The resident said, They take good care of the wound and wound vac, and the wound is getting a lot better . This surveyor asked the resident if there was a specific time when staffing is more of a problem. The resident replied, No they seem to be short randomly and at any time. I love taking showers, I feel cleaner. They always do wash me off and make sure I'm clean, but it is not the same as having a shower. I think I just feel dirty because of the wound vac and it makes me feel like I stink. An interview, on 3/28/19 at 10:00AM, revealed Resident (R#1) said she thought she may have told a nurse and another NA she preferred showers over bed baths. R#1 stated NA#109 makes sure I get my showers now. R#1 said, They do wash me off, and I know they keep me clean. I don't know if it's because of the wound vac that makes me think I stink. But I feel like I stink, I want showers. After reviewing residents records it was noted that the resident was diagnosed with [REDACTED]. The surveyor asked the resident if the facility took any precautions when she had[DIAGNOSES REDACTED]. The resident stated, Yes, I have been in isolation for [MEDICAL CONDITION] and the staff always wore gowns and mask when coming in my room to take care of me. Review of R#1medical records revealed the resident was admitted to the facility on [DATE], for rehabilitation due to complications and generalized weakness from a hernia repair surgery and chronic disease processes. The resident needed extensive assistance with all activities of daily living. Some significant [DIAGNOSES REDACTED]. The resident was transferred and admitted to the hospital multiple times since being admitted to the facility. - R#1 was sent to the hospital and admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. - R#1 was sent to the hospital and admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. - R#1 was sent to the hospital and admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. - R#1 was sent to the hospital and admitted to the hospital on [DATE] to rule out a [MEDICAL CONDITION]; and was discharged back to the facility on [DATE]. - R#1 was sent to the hospital and admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. - R#1 was sent to the hospital and admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Review of the facility shower records showed Resident #1 had no showers documented in the months of August, September, October, November, (MONTH) (YEAR). Resident #1 only had one (1) shower in the month of January, on 01/01/19; one (1) shower in the month of February, on 02/01/19; and three (3) showers so far in the month of March, 03/05/19, 03/21/19, and 03/25/19. There are no records for R#1 showing she received any showers anytime in (YEAR) after her admission on 08/22/18. An interview with Center Nurse Executive (CNE, formerly known as director of nursing), on 03/28/19 at 11:47 AM, confirmed there was no documentation of showers for R#1 other than five (5) showers documented this year in 2019. The CNE confirmed the resident, even though out of the facility hospitalized for [REDACTED]. i) Resident #2, Incontinence Care Observations of incontinence care for Resident (R#2) by Nurse aide (NA#67), on 03/26/19 at 4:27 PM, revealed no issues or concerns. NA#67 transferred the resident with the assistance of another aid using a Hoyer lift. Incontinence care was provided with no breach in infection control principles. Staff interacted appropriately with resident and explained what they were doing. Sister-in-law was present visiting the resident at the time, neither the resident nor visitor had any complaints concerning the care the resident received at the facility. They expressed that the nurse aids worked hard, but at times a call light might take up to twenty minutes or more to be answered because they are busy. Both the sister-in-law and resident said the facility could use some more staff, because the NAs work so hard and sometimes do double shifts. R#2 said staff always provided her care and everything she needed, just sometimes she had to wait a little bit, but the NAs always take good care of the resident.",2020-09-01
2816,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2018-11-09,583,D,0,1,KBQP11,"Based on observation and staff interview, the facility failed to ensure privacy was provided to one (#20) of one sampled resident for whom the administration of medications via a feeding tube was observed. The facility census was 128. Findings included: On 11/06/18 at 2:05 PM, Licensed Practical Nurse (LPN) #81 was observed as she administered medications via a feeding tube to Resident #20. The LPN did not pull the privacy curtain or close the door to administer the medication. This exposed Resident #20 to anyone who walked by in the hallway. On 11/06/18 at 2:08 PM, the observation of administering medication via a feeding tube was reviewed with LPN #81. She acknowledged she had left the hallway door opened. She stated she should have closed the door to administer the medications via the resident's feeding tube.",2020-09-01
2817,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2018-11-09,641,D,0,1,KBQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed for one (#23) of 27 sampled residents whose MDS assessments were reviewed. The facility census was 128. Findings included: On 11/07/18 at 12:52 PM, the electronic clinical record of Resident #23 was reviewed. The clinical record documented the resident had [DIAGNOSES REDACTED]. The admission nursing assessment, dated 12/02/16, documented Resident #23 had a feeding tube. The quarterly MDS assessment, dated 06/04/18, documented Resident #23 had no swallowing disorder and did not have a feeding tube. The annual MDS assessment, dated 08/24/18, documented Resident #23 had no swallowing disorder and had a feeding tube. The care plan, most recently reviewed/revised 08/24/18, documented Resident #23 had an enteral feeding tube to meet nutritional needs (related to) dysphagia. On 11/07/18 at 2:26 PM, the record review regarding the feeding tube and the [DIAGNOSES REDACTED]. The DON stated the MDS assessment, dated 06/04/18, was not accurate in regard to the documentation of the feeding tube and the swallowing disorder. She also stated the MDS assessment, dated 08/24/18, was not accurate as to the documentation of the swallowing disorder.",2020-09-01
2818,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2018-11-09,657,D,0,1,KBQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to ensure the care plan had been reviewed/revised to reflect the resident's current smoking status. This affected one (#28) of 27 sampled residents whose care plans were reviewed. The facility census was 128. Findings included: On 11/07/18 at 10:01 AM, the clinical record of Resident #28 was reviewed. The electronic record documented the resident had [DIAGNOSES REDACTED]. The most recent smoking evaluation, dated 05/18/18, documented Resident #28 was not able to safely hold a cigarette and did not have the ability to light a cigarette. The evaluation concluded the Resident not allowed to smoke. The care plan, most recently reviewed/revised 08/24/18, documented a problem related to the resident not being allowed to smoke per her smoking assessment. Interventions included the patient will not smoke x 90 days, inform and reinforce smoking restriction, inform family and significant others of the patients inability to smoke and to reassess patients inability to smoke with any change in condition. On 11/05/18 at 4:28 PM, during an interview in the resident's room, Resident #28 stated she smoked at the facility when a friend brought in cigarettes to her. She stated she had smoked most recently on 10/31/18. At 4:48 PM on 11/05/18, the Administrator stated the resident was allowed to go out into the courtyard with friends who brought cigarettes to her and supervised her smoking. On 11/06/18 at 11:26 AM, during an interview with the Director of Nursing (DON) and Administrator, the DON stated Resident #28 was allowed to smoke when her friends and family supervised her smoking in the courtyard. Despite the smoking evaluation which documented the resident was not allowed to smoke, the Administrator stated the resident was permitted to smoke when she was supervised by family or friends. The DON acknowledged the care plan did not address the circumstances under which Resident #28 was allowed to smoke. She stated the care plan should have been revised to document the circumstances under which the resident was allowed to smoke. The DON stated the facility's smoking policy and procedure had not been followed to document the resident's smoking status in the care plan. She further stated the policy and procedure had not been followed to update the care plan regarding the resident's smoking status.",2020-09-01
2819,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2018-11-09,684,J,0,1,KBQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff and resident interviews, and facility policy review, the facility failed to ensure two (Resident #58 and #76) of four sampled residents were provided appropriate care and services related to standards of practice and competency for Intravenous (IV) therapy resulting in an Immediate Jeopardy. On 11/08/18 at 4:27 PM, the Administrator and the Director of Nursing (DON) were notified verbally that Immediate Jeopardy existed and began on 10/26/18, when Resident #58 was readmitted with a peripheral inserted central catheter (PICC). Resident #58 and #76 was ordered to have IV therapy. An audit provided by the Administrator and the Director of Nursing (DON) on 11/09/18 at 8:30 AM revealed LPN #3, #27, #133, #156 and #177 performed IV therapy for Resident #58 and #76 without having IV training and verification of such. Immediate Jeopardy was abated on 11/08/18 at 6:47 PM, The facility completed a full audit of all residents who had IV access that would require IV therapy. The facility revised the staffing schedule to ensure a Registered Nurse (RN) or an IV trained and verified LPN would be performing IV therapy for the four residents with IV access and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity level two (no actual harm, with potential for more than minimal harm that is not immediate jeopardy) until LPNs are trained and competent with IV therapy. See F726 (Staff Competency) for additional information. Findings included: 1. A comprehensive chart review for Resident #58 was conducted on 11/06/18 at 11:07 AM and noted the following information. The Admission Record identified Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the hospital records, Resident #58 was admitted to the hospital on [DATE] after a CT (computerized tomography) scan identified the resident had [MEDICAL CONDITION]. Resident #58 was diagnosed with [REDACTED]. Resident #58's re-admission Physician order [REDACTED]. The document stated under the section Other Orders, a peripherally inserted central catheter (PICC) with two lumens (a lumen is tube for obtaining blood or giving IV medications through) was in place. A PICC line is a thin, soft, long catheter (tube) that is inserted into a vein in the upper arm, leg or neck. The tip of the catheter is positioned in a large vein that carries blood into the heart. The PICC line is used for long-term intravenous (IV) antibiotics, nutrition or medications, and for blood draws, which is considered IV therapy. An initial Nursing assessment dated [DATE] noted Resident #58 had a PICC line upon admission back to the facility. A care plan was initiated on 10/27/18 and documented the PICC line was inserted due to a pending [MEDICAL CONDITION] start date. There was no information on the care plan that directed the clinical staff to change the transparent dressing or to change the needleless connection device after blood was taken from these devises. A comprehensive Minimum Data (MDS) assessment dated [DATE], was reviewed. Section C for Cognition revealed a Brief Interview for Mental Status (BIMS) test scored Resident #58 as 15 out of 15 which indicated the resident was fully cognitively intact. An interview was conducted with Resident #58 on 11/05/18 at 3:07 PM. During this interview the resident showed her PICC site on her right arm. The resident said that she needs her blood drawn from the needleless connection device since she has tiny veins. During this interview, her transparent dressing site was observed and there was a hand-written area dated 10/22/18. Continued review of the chart on 11/06/18 at 11:07 AM, revealed a document entitled Central Line Catheters for the month of (MONTH) (YEAR) and (MONTH) (YEAR) had an area identified as Change Needleless Connection Device. For the month of (MONTH) (YEAR), the transparent dressing was scheduled to be changed on 10/27/18. This area was not signed off as completed. There was a section on this form that directed staff to sign off if needleless connection devices were changed after a blood draw. The laboratory results were reviewed and noted the Resident #58 had blood draws on 10/29/18. There was no documented evidence on the central line catheter form that the needleless connection devices were changed after this blood draw. For the month of (MONTH) (YEAR), the central line form identified Resident #58 had her transparent dressing changed on 11/05/18, ten days after admission. The resident also had a blood draw on this same date. There was no documented evidence on the central line form that indicated the needleless connection devices were changed after the blood draw. On 11/06/18 at 1:24 PM, in an interview with LPN #156 on the unit, she revealed she did not have a great deal of experience with PICC lines but had performed IV therapy. She stated infection control was critical with the PICC line device. She stated the time frame for changing the dressing of a PICC line was three days and the orders were pre-printed on the PICC line form. The DON confirmed LPN #156 signed the PICC line flush order for Resident #58 as completed on 10/27/18. The audit completed by the Administrator and the DON could not verify IV training for LPN #156. Another interview was conducted with Resident #58 on 11/06/18 at 2:15 PM. She verified that she had blood drawn from her PICC line since her readmission to the facility. She said that she was unsure if the clinical staff changed the tips of the PICC lumen after each blood draw or not. An interview was conducted with Registered Nurse (RN) #173 on 11/06/18 at 3:34 PM. RN #173 verified the PICC line connections devices had not been changed when the dressing was changed on 11/05/18. She stated the needleless connection devices were to be changed after each blood draw. On 11/07/18 at 10:27 AM, the DON was interviewed. She stated she was not aware that LPN's were performing IV therapy without training and verification. The DON and the Administrator were interviewed on 11/07/18 at 11:10 AM. The DON confirmed there was no evidence to show the needleless connection devices were changed after the blood draws. On 11/08/18 at 9:46 AM, a telephone interview was conducted with LPN #3 related to Resident #58 PICC line orders. LPN #3 stated, she was the nurse who signed off on the central line and said she was trained in IV and PICC therapy. She stated she could only flush the PICC line. LPN #3's initials were verified by the DON as documented performing IV therapy for Resident #58. The audit completed by the Administrator and the DON confirmed LPN #3 was not verified as trained in IV therapy. During interview with the DON on 11/08/18 at 11:30 AM, she confirmed the dressing had not been changed since the resident was re-admitted to the facility on [DATE]. According to the Central Line Catheter flowsheet, the dressing and connection devices were scheduled to be changed on 10/27/18 on the 7A - 7P shift. The box to document completion was blank. On 11/08/18 at 11:37 AM, an interview was conducted with RN #15. RN #15 confirmed LPN #3 was the nurse who flushed the PICC line in (MONTH) and (MONTH) (YEAR). She stated she was not aware of LPN #3 performing IV therapy without training. 2. A focused chart review for Resident #76 was conducted on 11/08/18 at 12:30 PM. The following information was reviewed related to Resident #76's IV port (a round disc placed under the skin with an internal catheter for intravenous access): The Admission Record identified Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan for Resident #76 initiated on 05/12/16, revealed an Infusaport (an IV port placed in the upper chest for intravenous access). The goal stated, the resident would have no complications related to IV therapy. The interventions stated, flush the port per facility policy and RN to access and flush port every month as ordered. Review of the form titled, Central Venous Access Device ([MEDICAL CONDITION]) - Physician/Licensed Independent Practitioner (LIP) Order Sheet dated 10/01/18 was completed. The order stated, RN to access 28th of month Flush with 10ml (milliliters) of NS (normal saline) then de-access (sic) (de-access) (to remove the needle and catheter used to flush, give medications or obtain blood through). Review of Resident #76's Central Line Catheter Protocol orders for the month of (MONTH) (YEAR) were completed. Resident #76 was prescribed tigecycline (antibiotic) 100mg (milligrams) IV for one dose then, 50 mg IV every 12 hours for five days for a urinary tract infection. Also, RN: access 1P (infusaport) 28th each month, Flush 10ml with NS (normal saline) and deaccess (sic) (de-access). The Infusion Medication and Central Line Catheters flowsheets for the month of (MONTH) (YEAR) was reviewed. The medication and the IV flush order for (MONTH) (YEAR) was documented as completed twice a day for five days and signed by the nurse administering. LPN's #3, #27, #133, #156 and #177 were documented as flushing and/or administering the IV antibiotic medication. In an interview with the DON on 11/08/18 at 2:34 PM, she confirmed two of the LPN signatures identified on the Infusion Medication and Central Line Catheter flowsheets were not trained in IV therapy. On 11/08/18 at 2:48 PM, LPN #27 was interviewed by phone. She stated she had not completed an IV course. She stated she accessed Resident #76's IV port by hanging the IV medication and hooking the medication solution bag to the tubes in the port. She stated after the antibiotic medication was completed, she flushed the IV port tube. The facility's policy titled, IV Nursing Qualifications and Education dated revised 03/15/16 was reviewed. The policy stated, .The (company name) licensed nursing staff may perform infusion therapy activities based on the state regulations and must successfully complete a (company name) infusion therapy education program, a current pharmacy vendor provided program, or the Test - Out.licensed staff must demonstrate skills competency prior to administering and managing infusion therapy.licensed staff nurses must complete the IV Skills Self - Assessment to evaluate experience.competency .will be maintained in the employee's personnel file. The undated Competency Testing Module was reviewed. The note for newly hired nurses' states information related to IV therapy under the LPN scope of practice versus the RN scope of practice. The form stated, State requirements must be followed when more restrictive. Under the title, Tier 1, the LPN cannot perform during orientation until completion of Management of Infusion Therapy Course and associated competencies. The facility policy entitled, Central Vascular Access Device ([MEDICAL CONDITION]) Dressing Change dated as revised on 05/01/16. The policy stated, .Licensed nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Competency validation documented in accordance with organizational policy.the dressing was to be changed, .24 hours post insertion or upon admission and at least weekly. The facility policies entitled Central Vascular Access Device ([MEDICAL CONDITION]) Needleless Connector Change dated as revised 05/01/16. The policy stated, .Needleless connectors are changed .Upon admission at least every 7 days .After blood is drawn through the needleless connector .Any time the integrity of the needleless connector is in question .",2020-09-01
2820,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2018-11-09,689,D,0,1,KBQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview and policy review, the facility failed to ensure one (#28) of one sampled resident reviewed was assessed to determine safety when smoking. Additionally, the facility failed to document a resident required supervision to smoke. The facility identified a total of 9 residents who were allowed to smoke when friends/family provided supervision. The facility census was 128. Findings include: On 11/07/18 at 10:01 AM, the clinical record for Resident #28 was reviewed. The electronic record documented the resident had [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 03/09/18, documented Resident #28 had no cognitive impairment, required supervision with ambulation and eating and required extensive assistance with most other activities of daily living (ADLs). The most recent smoking evaluation, dated 05/18/18, documented Resident #28 was not able to safely hold a cigarette and did not have the ability to light a cigarette. The evaluation concluded the Resident not allowed to smoke. The quarterly Minimum Data Set (MDS) assessment, dated 08/24/18, documented the resident had no cognitive impairment and was independent or required supervision with most ADLs. The care plan, most recently reviewed/revised 08/24/18, documented a problem related to Resident t#28 not being allowed to smoke per her smoking assessment. Interventions included the patient will not smoke x 90 days, inform and reinforce smoking restriction, inform family and significant others of the patient's inability to smoke and to reassess patients inability to smoke with any change in condition. On 11/05/18 at 4:28 PM, during an interview , Resident #28 stated she smoked at the facility when a friend brought in cigarettes to her. She stated she had last smoked when her friend brought in cigarettes on 10/31/18. At 4:48 PM on 11/05/18 , during an interview, the Administrator stated the Resident #28 was allowed to go out into the courtyard with friends who brought cigarettes to her and supervised her smoking. On 11/06/18 at 11:26 AM, during an interview with the Director of Nursing (DON) and Administrator, the DON stated Resident #28 was allowed to smoke when her friends and family supervised her smoking in the courtyard. She stated the resident had no smoking evaluation completed since 05/18/18. The DON acknowledged the facility's smoking policy and procedure had not been followed to re-evaluate quarterly the resident's smoking ability to smoke. Despite the smoking evaluation which documented the resident was not allowed to smoke, the Administrator stated Resident #28 was permitted to smoke when she was supervised by family or friends. The DON acknowledged the care plan did not address the circumstances under which the resident was allowed to smoke. She stated the care plan should have been revised to document the circumstances under which the resident was allowed to smoke. The DON stated the facility's smoking policy and procedure had not been followed to document the resident's smoking status in the care plan. She further stated the policy and procedure had not been followed to update the care plan regarding the resident's smoking status. The facility's smoking policy and procedure, most recently revised 07/24/18, documented: .The admitting nurse will perform a Smoking Evaluation on each patient who chooses to smoke .Patients will be re-evaluated quarterly and with a change of condition .A patient's smoking status - independent, supervised, or not permitted to smoke - will be documented in the care plan .The care plan will be updated as necessary .",2020-09-01
2821,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2018-11-09,726,J,0,1,KBQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of the State Board of Examiners for Licensed Practical Nurses, and review of the facility policy, the facility failed to ensure Licensed Practical Nurses (LPN) who performed the skill set of Intravenous (IV) therapy were competent and trained to perform IV therapy within their scope of practice and state regulations. The facility was unable to provide verification of competency and IV training for five (#3, #27, #133, #156 and #177) of 13 LPNs who were performing IV therapy. This practice resulted in Immediate Jeopardy. On 11/08/18 at 4:27 PM, the Administrator and the Director of Nursing (DON) were notified verbally that Immediate Jeopardy existed and began on 10/26/18, when Resident #58 was readmitted with a peripheral inserted central catheter (PICC). According to nurse standards of practice and state regulations, only Registered Nurses and trained LPNs with verification were to perform IV therapy. According to an audit provided by the Administrator and the DON on 11/09/18 at 8:30 AM, LPN #3, #27, #133, #156 and #177 performed IV therapy without having IV training and verification as required by the facility. Immediate Jeopardy was abated on 11/08/18 at 6:47 PM, The facility by completing a full audit of all residents who had IV access that would require IV therapy. The facility revised the staffing schedule to ensure an RN or an IV certified LPN would be performing IV therapy for the four residents with IV access and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity level two (no actual harm, with potential for more than minimal harm that is not immediate jeopardy) until LPNs were trained and competent with IV therapy including PICCs (peripheral inserted central catheters which is a thin, soft, long catheter (tube) that is inserted into a vein in the upper arm, leg or neck and positioned in a large vein that carries blood into the heart). See F883 (Facility Assessment), F867 (QAPI) and F684 (Quality of Care) for additional information. Findings included: Review of the State Board of Examiners for Licensed Practical Nurses on 11/06/18 at 3:56 PM, revealed the following: .Licensed Practical Nurses perform duties and procedures for which training has been provided during the 12-month training program. The administration of IV fluids is not a part of the standard curriculum for accredited schools of practical nursing in the state.Each LPN would have to have extra training after graduating and taking state boards. In an interview with staff development Registered Nurse (RN) #15, on 11/06/18 at 4:03 PM, it was revealed she was unaware of the scope of practice related to IV training and verification for LPNs. Interview with RN #15 on 11/08/18 at 10:12 AM, revealed she did not have copies of all of the LPN's IV training and verifications. She stated she should have requested and kept copies when the staff members were hired. An interview was conducted on 11/08/18 at 11:20 AM with RN #15. She stated an audit of LPN staff with IV training and verification was completed on 10/03/18. She stated a portion of the LPN staff were not IV trained. She did not provide the number of LPNs not trained in IV therapy. She notified the DON and the Administrator of the audit result. She stated she would not know which LPN was working out of their scope of practice because she did not have a copy of each LPN's IV to verify training. In an interview with RN #15 on 11/08/18 at 4:40 PM, she revealed she provided orientation for newly hired LPNs. She stated she has the new employees come in for two days of orientation and competency training on medication administration and IV care and competency. She stated, even if an LPN has verification of IV training, the LPN would still need to attend the pharmacy IV course per facility policy. She stated LPNs who were not IV trained should know better than to do something outside their scope of practice. She stated none of the newly hired nurses during orientation IV competency had ever told her they could not touch IVs due to not being trained. On 11/08/18 at 5:41 PM, RN #15 provided the Nursing Qualifications and Education policy regarding IV nursing and the revision was dated 03/15/16. The document was titled, Competency Testing Module. The policy revealed the following: . (the company) licensed nursing staff may perform infusion (IV) therapy activities based on state regulations and must successfully complete a (company) infusion (IV) therapy education program, a current pharmacy vendor provided program or the Test - Out.Newly hired nurses may complete the IV Skills Self-Assessment to evaluate experience.Verification of the nurses' completion of an infusion (IV) education program, ongoing training and skills competency, and attendance at in-services will be maintained in the employee's personnel file. A review of the new orientation Competency Testing module packet for nurses was completed on 11/08/18 at 5:41 PM. The following information was noted: .In order to assure that Nursing is able to deliver quality care in a safe manner. It is necessary to perform competency testing on license nurses. Part of the competency testing listed in the packet was Infusion Therapy Skills. The packet information stated, in order for a license practical nurse (LPN) to perform infusion therapy they must be in compliance with state regulations and must be followed. On 11/08/18 at 6:44 PM, the Administrator stated she had not been aware there were LPNs [MEDICATION NAME] outside of their scope of practice.",2020-09-01
2822,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2018-11-09,758,E,0,1,KBQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure four (Resident #113, #61, #36 and #112) of five sampled residents reviewed for unnecessary medications had proper indications for the use of an antipsychotic medication. There was also a failure to have adequate monitoring of target behaviors for the continued use of an antipsychotic medication. The facility census was 128. Findings include: 1. A comprehensive chart review was conducted on 11/06/18 at 3:58 PM. Per review of the Admission Record Resident #113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated as initiated 05/30/17, noted Resident #113 received [MEDICATION NAME] (an antipsychotic) for dementia with behaviors as evidenced by yelling, hitting/shaking and crying. The goal was the resident would have the smallest most effective dose without side effects. One of the interventions was to complete the behavior monitoring flowsheets for yelling, hitting/shaking and crying. According to the care plan list of gradual dose reductions and medication increases; [MEDICATION NAME] 12.5 mg (milligrams) was added in the morning on 03/08/18. The Behavior Monitoring and Intervention records revealed the following information: For the month of (MONTH) (YEAR), the monitoring record identified the resident had five episodes of yelling, which were redirected by staff and documented as effective. For the month of (MONTH) (YEAR), the monitoring record identified five episodes of crying, which was redirected by staff and documented as effective. According to the care plan list of gradual dose reduction and medication increases dated 06/06/18, the [MEDICATION NAME] was increased to 25 mg in the morning. Approximately two weeks later on 06/22/18, the [MEDICATION NAME] was increased 50 mg two times a day. The Minimum Data Set (MDS) assessment dated [DATE], Section C for Cognition documented the Brief Interview for Mental Status (BIMS) noted Resident #113 scored a 7 of 15 which determined the resident was cognitively impaired. Section [NAME] for Behavior did not identify any behaviors such as hallucinations, delusions or that she was at risk for harming self or others. Section I for Active [DIAGNOSES REDACTED]. Under the same section, Resident #113 was not identified for [MEDICAL CONDITION], bi-polar or [MEDICAL CONDITION]. Section N for Medication identified Resident #113 was prescribed and had taken antipsychotic medication during the 7- day look back period. For the month of (MONTH) (YEAR), the Behavior Monitoring and Intervention record identified the resident had five episodes of a behavior symptom; however, the targeted behavior for monitoring was left blank. For the month of (MONTH) (YEAR), the monitoring record identified four episodes of yelling, which was redirected by staff and documented as effective. Two episodes of an unidentified behavior were documented, and the behavior description was left blank. An IDT [MEDICAL CONDITION]/therapeutic Medication Use Evaluation assessment dated [DATE] was reviewed with the following findings: Section titled, Evaluation, Behavior Trends Since the Last Evaluation, documented behaviors have increased. Section titled, In the Past 30 Days, documented an increase dose to psychotherapeutic/antipsychotic medications due to non-pharmacological interventions were ineffective. For the month of (MONTH) (YEAR), the Behavioral Monitoring and Intervention record identified three episodes in one day of yelling. Resident #113 was redirected by staff and documented the intervention as effective. An Interdisciplinary Team (IDT) [MEDICAL CONDITION]/therapeutic Medication Use Evaluation assessment dated [DATE] was reviewed with the following findings: Section titled, Evaluation, Behavior Trends Since the Last Evaluation, documented, no behavior symptoms, none present prior to this review. Section titled, In the Past 30 Days, documentation revealed non-pharmacological attempts of redirection, conversation, hydration/nutrition and environment change. An increase in the dose of prescribed psychotherapeutic/antipsychotic meds due to non-pharmacological intervention/s ineffective. Review of Progress Note History dated 09/11/18 was completed. The note documented, the patient was seen today .She appears comfortable and in no added distress .Her behaviors are controlled at this point and a reduction of dosage may be necessary. For (MONTH) (YEAR), the Behavioral Monitoring and Intervention record did not identify Resident #113 with behaviors. The facility did not provide the behavior monitoring sheets for the month of (MONTH) or (MONTH) (YEAR). The Consultant Pharmacist made recommendations on 09/14/18 to reduce the [MEDICATION NAME] to 25 mg in the AM (morning) dose and [MEDICATION NAME] to 5 mg in the bedtime dose. The end goal being to discontinue, while monitoring for re-emergence of target behaviors and/or withdrawal. The recommendation documented the resident had received [MEDICATION NAME] 50 mg for behavioral or psychological symptoms of dementia since (MONTH) (YEAR). The physician declined the recommendation. A physician's orders [REDACTED]. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of Resident #113's Progress Notes section of the record, revealed multiple entries from 06/02/18 thru 11/01/18 documenting the resident had no behaviors and/or the resident's condition related to behaviors have improved. On 11/06/18 at 9:30 AM, an observation of Resident #113 in the common area on unit in her wheelchair. Resident #113 was dressed and groomed, socially interacting with staff and other residents. She was offered a cup of fluids and smiled and drank the entire cup without complaint. An interview with Resident #113's roommate who was alert and oriented, was conducted on 11/07/18 at 10:00 AM in her room. The roommate stated they had been roommates for a long time and were like sisters. She stated Resident #113 has never became aggressive towards her. She stated Resident #113 had become agitated with the staff at times because she wanted to be left alone. She stated she had never seen any physical altercations with Resident #113 and the staff. An interview with Certified Nursing Assistant (CNA) #230 on 11/07/18 at 10:30 AM at the nurses' desk on the unit was completed. She stated she cared for Resident #113 on a routine basis and was familiar with her. She stated the resident had not had any aggressive behaviors in a while. She stated the resident had mood swings and would be crying at one point and agitated at another but would be easily redirected. CNA #230 stated, If the staff approaches her and she becomes agitated, just give her time and she can be redirected. She stated she was not afraid of Resident #113. She stated she did not think Resident #113 was a danger to herself or others. An interview with the Registered Nurse (RN) #173 was completed at the nurses' desk on the unit on 11/07/18 at 11:16 AM. She stated she does have to redirect Resident #113 at times after the resident gets upset or frustrated. She stated the resident was easily redirected, especially if you explain what you are going to do and why. RN #173 stated Resident #113 was much better to accept care when she was in bed. She stated when the resident was up out of bed, she liked to be out in the crowd and that would occasionally cause her to become loud and refuse care. She stated she could not recall a time when Resident #113 actually struck someone. She stated she monitors Resident #113 for an increase in agitation and refusal of care. She stated Resident #113 was not a danger to herself or others. A review of the manufacturer's guidelines was completed on 11/08/18 at 8:36 AM. The manufacture's guidelines were reviewed on [MEDICATION NAME] manufacturer's insert stated, Indications for use, [MEDICAL CONDITIONS] [MEDICAL CONDITION] . [MEDICATION NAME] may cause serious side effects, including: .1. risk of death in the elderly with dementia. Medicines like [MEDICATION NAME] can increase the risk of death in elderly people who have memory loss (dementia). [MEDICATION NAME] is not for treating [MEDICAL CONDITION] in the elderly with dementia [MEDICATION NAME] may cause serious side effects, including: 1. risk of death in the elderly with dementia. Medicines like [MEDICATION NAME] can increase the risk of death in elderly people who have memory loss (dementia). [MEDICATION NAME] is not for treating [MEDICAL CONDITION] in the elderly with dementia . An interview was conducted with the Regional Medical Director and Nurse Practitioner (NP) on 11/08/18 at 8:26 AM in the conference room. The NP stated she gathers information regarding resident behaviors by interviewing the staff. She stated she did not review the behavioral monitoring flowsheets to confirm staff interviews regarding the resident behaviors. During the interview the Regional Medical Director, she stated she did not like the use of antipsychotic medications and more education was needed. The NP stated she does not participate in the Quality Assurance (QA) committee meetings during which antipsychotic medication use was discussed. 2. A chart review was conducted on 11/06/18 at 12:49 PM. Per review of the Admission Record Resident #61 was admitted to the facility on [DATE]. A care plan dated as initiated 06/19/15, noted Resident #61 received [MEDICATION NAME] (an antipsychotice) for dementia with behaviors as evidenced by yelling, hitting, refusal of care and agitation. The goal was to place the resident on the lowest dose. One of the interventions was to complete the behavior monitoring flowsheet for unprovoked verbal outbursts, yelling, hitting, and refusal of care. A physician's orders [REDACTED]. The Behavior Monitoring and Intervention records revealed the following information: For 03/18, the monitoring record did not identify Resident #61 with behaviors. For the month of 04/18, the monitoring record identified the resident had 12 episodes of cursing at others. The resident was redirected by staff The Consultant Pharmacist made recommendations on the [MEDICATION NAME] on 04/11/18 to reduce the [MEDICATION NAME] from 5 mg to 2.5 mg to be administered each day. The medical provider agreed, and the [MEDICATION NAME] was reduced on 04/20/18. On 04/20/18 the Nurse Practitioner (NP) reduced the [MEDICATION NAME] to 2.5 mg to be administered each day for dementia with behaviors as evidenced by yelling, hitting, and refusing care. For the month of 05/18, the resident had 11 episodes of screaming and being disruptive over four days. The month of 06/18, the monitoring record identified the resident had three episodes of screaming at others for one day. During the month of 07/18, the monitoring record noted the resident had seven episodes of screaming and being disruptive over 2 days. For the month of 08/18, the resident had six episodes of screaming and being disruptive in one day. In the month of 09/18, the monitoring record identified the resident had three episodes of screaming at others during the month. For the month of 10/18, the resident had no behaviors identified. A Progress Note dated 06/29/18 written by a medical provider noted under .Psychiatric . Resident #61 was confused and cooperative. Under .Plan . the goal was to continue the [MEDICATION NAME] as ordered and to adjust as needed for comfort. A medical provider progress note dated 07/09/18 noted under .Psychiatric . the resident was pleasantly confused and cooperative Another recommendation dated 07/11/18 was made for a possible gradual dose reduction on the [MEDICATION NAME], specifically, .Please consider a gradual dose reduction to [MEDICATION NAME] 2.5mg every other day with the end goal of discontinuation of therapy. The medical provider declined since Resident #61 had a gradual dose reduction on 04/20/18. On 10/12/18 the pharmacist asked to consider a gradual dose reduction of [MEDICATION NAME] 2.5 mg to be administered every other day with the goal of discontinuing this medication. The medical provider declined and documented, .making progress conversing, comfort care . and to change the [MEDICATION NAME] .could impede . A significant change Minimum Data Set (MDS) assessment dated [DATE], Section C for Cognition Brief Interview for Mental Status (BIMS) noted Resident #61 scored 4 of 15 which determined the resident was severely cognitively impaired. Section [NAME] for Behavior did not identify any behaviors such as hallucinations, delusions or that he was at risk for harming himself or others. Section I for Active [DIAGNOSES REDACTED]. Under this same section, Resident #61 was not identified as [MEDICAL CONDITION], bi-polar or psychotic. Section N for Medication identified Resident #61 took an anti-psychotic medication during the 7-day look back period. A medical provider progress note dated 10/01/18, stated the resident was confused under a section entitled .Psychiatric . The section identified as .Plan . the provider documented the resident had advance dementia and to continue current regimen and noted his behaviors were controlled. An interview was conducted with CNA #212 on 11/06/18 at 2:20 PM. The staff member said he was not fearful of Resident #61 and said the resident did not hit out at all. CNA #212 said the resident would become verbally abusive occasionally. The CNA stated the resident did not yell out constantly. LPN #27 was interviewed on 11/06/18 at 2:25 PM. The LPN stated Resident #61 was not a danger to himself or to others and she was not afraid of him. The staff member said the resident did not hallucinate but he did make up stories occasionally. She again the resident was calmer than he used to be. On 11/07/18 12:25 PM, Resident #61 was in the dining room. While in the dining room, he was propelling himself and ran into another resident's walker and he apologized to this resident. He was smiling and talking with staff members, Staff were appropriate with redirection and interaction with Resident #61. A review of the manufacturer's guidelines was completed on 11/08/16 at 8:36 AM. The manufacturer's guidelines were reviewed on [MEDICATION NAME] manufacturer's insert stated, WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED [MEDICAL CONDITION] See full prescribing information for complete boxed warning. o Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. [MEDICATION NAME] is not approved for the treatment of [REDACTED]. 3. A chart review was conducted on 11/07/18 at 9:01 AM. Per review of the Admission Record, Resident #36 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A care plan dated as revised 12/13/17, noted Resident #36, was prescribed [MEDICATION NAME] (antipsychotic) for dementia with increasing behaviors as evidenced by wandering and exit seeking. The interventions were to offer support when the resident was in a distressed mood, to encourage her to attend activities, to refocus the resident on something positive, and to allow time for the resident to express feelings. A document entitled [MEDICAL CONDITION]/therapeutic Medication Use Evaluation dated 03/06/18 stated Resident #36 had no change in behaviors and a gradual dose reduction would be considered when the resident was .Clinically Stable . A Progress Note dated 03/20/18 written by a medical provider noted under .Psychiatric . Resident #36 was identified as alert and oriented times one (the resident knows self) Under .Plan . there was no mention of Resident #36's behavior. A medical provider progress note dated 03/28/18 noted under .Psychiatric . the resident was noted to be alert and oriented times one. Under the plan for the resident, there was no mention of the resident's behaviors. This same information was identified in a medical provider progress note dated 05/24/18. There was another form dated 06/06/18 which included the same information, that is, there were no new behaviors and a gradual dose reduction would be considered once the resident was clinically stable. Another evaluation form was completed on 08/30/18 and again the form noted there were no new behaviors and a gradual dose reduction would be considered once the resident was clinically stable. A significant change MDS assessment dated [DATE], Section C for Cognition BIMS Resident #36 scored 0 of 15 which determined the resident was severely cognitively impaired. Section [NAME] for Section [NAME] for Behavior did not identify any behaviors such as hallucinations, delusions or that she was at risk for harming herself or others. Section I for Active [DIAGNOSES REDACTED]. Under this same section, Resident #36 was not identified as [MEDICAL CONDITION], bi-polar or psychotic. Section N for Medication identified Resident #36 took an anti-psychotic medication during the 7-day look back period. On 09/12/18, this form noted the resident experienced no new behaviors. Under a section .Additional Comments of additional related meds (medications) not listed above . It noted the resident failed a gradual dose reduction over a year ago on 4/17, 7/17, and on 8/29/17. On 09/05/18, a Progress Note identified the resident was stable and the [MEDICATION NAME] was prescribed for dementia with behaviors as evidenced by yelling, hitting staff, aggression to other residents and refusal of care. There was a physician order [REDACTED]. On 09/13/18, a physician order [REDACTED]. The Behavior Monitoring and Intervention records were reviewed from (MONTH) through (MONTH) (YEAR). ,The monitoring record did not identify Resident #36 with wandering behaviors. The behavior records documented Resident #36 was monitored for yelling out, refusal of care, and hitting. An interview was conducted with CNA #221 on 11/07/18 at 11:55 AM. The staff member said that she has never had any problems working with Resident #36. She said it all depends on the approach that you have with her. The staff member said the resident is not violent and she does not yell out constantly, nor was she a threat to herself or to others. An interview was conducted with CNA #53 on 11/08/18 at 9:04 AM. She said Resident #36 can be physically aggressive at times. She confirmed the resident did not wander, no other residents were fearful of the resident, and said the resident did not see things that were not there. An interview was conducted with the Regional Medical Director and Nurse Practitioner (NP) on 11/08/18 at 8:26 AM. The NP said she gathers information, regarding resident behaviors. from the nursing staff. During this interview the physician said she did not like to use antipsychotic medication and more education is needed Per NP, she does not participate in the Quality Assurance (QA) meeting in which antipsychotic medication use was discussed. A conference call interview was conducted with the Consultant Pharmacist on 11/08/18 at 11:00 AM. Also present during this telephone interview, the DON and the Administrator were also present. The Pharmacist stated she looks at the residents' diagnoses, she reviews if an AIMS (Abnormal Involuntary Movement Test) test was completed regularly. She also stated that she reviewed behavioral records. 4. On 11/06/18 at 3:14 PM, review of the clinical record revealed an admission history form dated 12/03/13. The admission history documented Resident #112 was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment date 10/23/18 documented that Resident #112 had a Brief Interview for Mental Status (BIMS) of six of 15; thereby, indicating significant memory impairment. Resident #112 required extensive assistance of one to two people to perform all activities of daily living (ADLS). Per the MDS, the resident had not had any behaviors since the previous MDS dated [DATE]. A Plan of Care (P[NAME]) dated 08/21/18 stated, Resident has a history of anxiety and depression; she receives [MEDICATION NAME] for behaviors as exhibited by exit seeking and agitation, anxiety, yelling, scooting self across floor. The goal for the P[NAME] was to have the smallest most effective dose without side effects throughout next review date. On 11/06/18 at 3:14 PM, Resident #112's clinical record was reviewed. Resident #112 was on Hospice. On 08/24/18, the physician orders [REDACTED]. Review of the Behavior Monitoring form documented that Resident #112 exhibited crying and yelling on 08/24/18. That was the only day in (MONTH) that a behavior was documented. There were no documented behaviors on the Behavior Monitoring Form from 08/24/18 through 11/06/18. Resident #112 was started on [MEDICATION NAME] on 05/23/18 with increases documented on 05/31/18, 06/05/18 and 08/24/18. On 11/07/18 at 10:23 AM, CNA #227 was interviewed. CNA #227 stated Resident #112 did not act out or did she observe any behaviors when working with her. On 11/07/18 at 10:27 AM, LPN # 80 was interviewed. LPN #80 stated recently Resident #112 had not had any behaviors. He stated that a few months ago Resident #112 would call out help me and get herself to the floor and scoot her bottom across the floor. On 11/07/18 at 9:50 AM, Resident #112 was observed lying in bed. Resident was sleeping without any signs of behaviors. On 11/08/18 at 8:33 AM, Nurse Practitioner (NP) #185 was interviewed. NP #185 stated that she could not recall why the [MEDICATION NAME] was increased. She thought it may have been something that hospice services requested but could not confirm. NP #185 stated that she gets most of her information from talking with the nursing staff. NP #185 had not reviewed the behavior monitoring forms. NP #185 ordered that the [MEDICATION NAME] be increased on 08/24/18. On 11/08/18 at 9:45 AM, the RN #255, the hospice nurse was interviewed by telephone. RN #255 stated Resident #112 was originally brought on to hospice services for her decreasing cardiac condition, but they have changed her terminal [DIAGNOSES REDACTED]. When Resident #112 returned from a hospital visit in (MONTH) of (YEAR), the facility and Resident #112's daughter observed an increase in crying and restlessness at night. That was why the [MEDICATION NAME] was started. RN #255 stated hospice will commonly order [MEDICATION NAME] for dementia with behaviors. RN #255 was not aware that the use of [MEDICATION NAME] for dementia with behaviors was not an appropriate [DIAGNOSES REDACTED]. RN #255 stated , the facility is not seeing behaviors because we increased her [MEDICATION NAME]. On 11/08/18 at 11:38 AM, LPN #182 was interviewed. LPN #182 stated Resident #112 will become more agitated in the afternoon, but that there was no true pattern to her behaviors. LPN #182 had not documented any behaviors for Resident #112. On 11/08/18 at 11:40 AM, Resident #112 was observed up in the Geri-chair, in the hallway by the nurses station. She appeared to be alert with no behaviors noted. On 11/08/18 at 11:53 AM, LPN #88 was interviewed. LPN #182 stated Resident #112 will still try to get out of bed and scoot herself across the floor. LPN #182 reviewed the last couple of months of Behavior Monitoring forms and stated that he did not see where the staff had been tracking any behaviors. LPN #182 stated, wW (nursing staff) need to do a better job at tracking our residents' behaviors.",2020-09-01
2823,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2018-11-09,761,D,0,1,KBQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure one (transitional care unit (TCU) ) of one medication refrigerator which was not in a medication room was locked. The facility census was 128. Findings include: On 11/06/18 at 10:20 AM, a refrigerator used for medication storage was observed to be unlocked in the TCU nurses' station. The refrigerator contained a [MEDICATION NAME] pen (used to control high blood sugar), two Bydureon pens (used to control high blood sugar), Firvanq solution (an antibiotic), a vial of [MEDICATION NAME] insulin, and a vial of influenza vaccine. At 10:27 AM on 11/06/18, the observation of the unlocked medication refrigerator was reviewed with Registered Nurse #210. She stated the medication refrigerator was supposed to be locked at all times.",2020-09-01
2824,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2018-11-09,812,E,0,1,KBQP11,"Based on observations, staff interviews, and facility policy review, the facility failed to ensure that staff sanitized a thermometer prior to taking food temperatures on one unit of a sample of three dining rooms. The facility also failed to ensure that two microwaves of three and one refrigerator out of three, located in resident dining areas, were cleaned, and the facility failed to ensure that two of the three dining rooms had clean serving areas. The facility census was 128. Findings included: 1.On 11/05/18 at 12:07 PM, the North dining room was observed. A Dietary Aide (DA) #44 was observed to set up the noon meal. DA #44 was observed to take the thermometer from the case and without sanitizing the probe, placed the thermometerin the mashed potatoes. The staff member took the thermometer out of the mashed potatoes and proceeded to take the thermometer to the sink, rinsed it off, and then wiped the probe off with a paper towel. DA #44 DA #44 took the thermometer and placed it into the potato soup. DA #44 went to the sink and rinsed the probe off and wiped it with a paper towel and stuck the probe into the steak fries. She repeated this action to all other food items ready to be served and included pulled pork and pureed pork. During this observation the staff member was interviewed, and she said she normally sanitizes the probe prior to taking food temperatures. 2. The North dining room was observed at 11/06/18 at 2:59 PM. The refrigerator, located in the kitchenette of the dining room, was opened. There was a dried white substance on the bottom. A microwave located next to the refrigerator was opened. The inside top of the microwave was greasy to touch. The inside door of the microwave was also greasy. There was a heated dry well, and three drawers on the left side of the well. There were raised brown spots and sticky grime upon touch. 3. The Transitional Care Unit (TCU) dining room was observed 11/06/18 at 3:07 PM. The microwave was opened and there was a thick film of grime, upon touch, on the inside top of the microwave. The inside door of the microwave had splattered brown material. An induction cooler was located on the bottom shelf located on the right side of the kitchenette. There was grime on the heat source of the induction cooler. The drawer located next to the heated well was opened. Located on the inside of the drawer were multiple brown drops of material. Located in this same drawer were two boxes of gloves, one box of probe wipes and a food thermometer. An interview was conducted with the Dietary Manager on 11/06/18 at 3:14 PM, and he stated the microwaves were used by Certified Nursing Assistants to reheat meals for residents. 4. On 11/07/18 at 12:00 PM the refrigerator located on the North dining area was opened and a dried white substance was on the bottom of the refrigerator. The microwave located next to the refrigerator was opened and a greasy substance, by touch, was identified on the top. At 11/07/18 at 12:03 PM, the Dietary Manager was interviewed, and he said the kitchenettes were to be cleaned by the food server after each meal. 5. An observation was made during the meal service in the TCU -on 11/06/18 at 12:00 PM. The microwave was open and there was a dry dark yellow on the inside of the door as well as an oily substance, by touch, on the inside of the door and on the inside top of the microwave. The temperature log was completed through 11/05/18. There were no daily temperatures taken for 11/06/18 and .An interview was conducted with Licensed Practical Nurse (LPN) #119during this observation. LPN #119 stated housekeeping was to clean the microwave and to take the temperatures of the refrigerator. An interview was conducted with the Dietary Manager on 11/07/18 at 12:35 PM while in the North dining room. He said there were probe wipes to sanitize thermometers located in the drawers of the kitchenette. Another interview was conducted with the Dietary Manager on 11/07/18 at 2:40 PM. He stated his expectation was the thermometer probe was to be sanitized prior to taking temperatures of food items. He stated that temperatures were to be taken daily. An interview was conducted on 11/07/18 at 3:08 PM with the Registered Dietician (RD). The RD stated that she conducts audits of the kitchen monthly. She said the three kitchenettes are not monitored by her as frequently. She said her expectation was for staff to sanitize the probe of the thermometer prior to placing it into food items. She also confirmed temperatures were to be taken daily. A facility policy entitled, Environment dated as revised 09/17 noted, .The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls .The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces . There was no mention of the facility's kitchenettes and who was responsible for cleaning these locations. A facility policy entitled, Food and Nutrition Services Policies and Procedures dated as revised 06/15/18, noted .To accurately monitor food temperatures, thermometers much be properly handled and maintained .Thermometers are washed, rinsed, sanitized, and air dried before and after each use to prevent cross-contamination . 6. On 11/05/18 at 12:08 PM, the lunch meal service was observed in the South Dining Room. The meal partially consisted of a pulled pork sandwich on a bun and French-fried potatoes. Cook #97 was observed picking up each bun with gloved hands and making the sandwich. In the middle of task, Cook #97 was observed taking off his glasses, cleaning his glasses with his apron, wiped under his eyes, and placed the glasses back on top of his head. Without washing his hands or changing his gloves, Cook #97 continued to pick up buns to make sandwiches. Additionally, Cook #97 stopped using the tongs he had to serve the French fries and began to use his gloved hands to plate the French fries. This practice continued for 27 minutes without changing gloves. On 11/07/18 at 12:33 PM, Dietary Aide (DA) #89 was interviewed. DA #89 stated that she was trained to always use tongs or scoops when handing ready to eat food. DA #89 continued that she was trained to wash her hands in between each glove change. On 11/07/18 at 12:51 PM, Cook #97 was interviewed. Cook #97 stated that he considered touching both the buns and the French fries with his gloved hands to be one task and he did not recall cleaning his glasses and then not changing his gloves. On 11/08/18 at 2:42 PM, the Dietary Manager (DM) #208 was interviewed. DM #208 stated that he had completed monthly trainings regarding hand washing and changing gloves. He stated that his expectation was that Cook #97 should have washed his hands and changed his gloves after cleaning his glasses. DM #208 stated that if Cook #97 had tongs for the French fries then his expectation would have been for him to use the tongs and not his hands to plate the French fries.",2020-09-01
2825,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2018-11-09,838,J,0,1,KBQP11,"Based on interview and review of the Facility Assessment Tool, the facility failed to ensure Licensed Practical Nurses (LPNs) were competent performing Intravenous (IV) therapy for the resident population. This affected five (#3, #27, #133, #156 and #177) of 13 LPNs performing IV therapy without IV training and verification of such. On 11/08/18 at 4:27 PM, the Administrator and the Director of Nursing (DON) were notified verbally that Immediate Jeopardy existed and began on 10/26/18, when Resident #58 was readmitted with a peripheral inserted central catheter (PICC). Resident #58 and #76 was ordered to have IV therapy. According to an audit provided by the Administrator and the DON on 11/09/18 at 8:30 AM, LPN #3, #27, #133, #156 and #177 performed IV therapy for Resident #58 and #76 without having IV training and demonstrating competency. Immediate Jeopardy was abated on 11/08/18 at 6:47 PM, The facility completed a full audit of all residents who had IV access that would require IV therapy. The facility revised the staffing schedule to ensure an RN or an IV certified LPN would be performing IV therapy for the four residents with IV access and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity level two (no actual harm, with potential for more than minimal harm that is not immediate jeopardy) until LPNs were trained and competent in IV therapy. See F726 (Staff Competency), F867 (QAPI) and F684 (Quality of Care) for additional information. The facility census was 128. Findings included: The Facility Assessment Tool dated 11/27/17 was reviewed on 11/08/18 at 8:30 AM. The facility assessment identified in Section, Acuity, that the facility offered IV medications to two residents at the time the assessment was completed. In the Section, Resident support/care needs, the facility documented IV (peripheral or central lines) therapy would be a service the facility provided. In the Section Staff training/education and competencies, the facility identified IV therapy as one of the educations and training competencies reviewed and provided throughout the year as needed related to resident acuity. In the Section, Working with medical practitioners, the company was to ensure licensed credentialed care providers were to adhere to standards of practice and if gaps in this system would be addressed as they arose. In Section Staff type, LPN's were identified as providing direct care for residents related to the facility acuity assessment. An interview was conducted on 11/08/18 at 11:20 AM with Registered Nurse (RN) #15 who was responsible for staff development. She stated she completed an audit on 10/03/18 regarding which LPN staff had IV certification. She stated she identified a number of LPN staff who were not IV trained to perform IV therapy. She notified the Director of Nursing (DON) and the Administrator of the result of her audit. She stated the facility did not have a system to monitor IV training of the LPN's. An interview was conducted on 11/08/18 at 12:30 PM with the Administrator and the DON. The Administrator and the DON stated they were notified of RN #15's audit regarding LPN IV certification. However, they were not aware any LPNs were performing IV therapy without verification of IV training. The Administrator stated she had not revised the facility assessment to reflect the need for standards of care and competencies for LPNs who were non-IV trained. She stated the facility does review annually the Facility Assessment Tool; however, had not been updating it as needed. She stated she was responsible for the facility assessment and coordinating the information incorporated in the facility assessment. On 11/09/18 at 10:05 AM, an interview with RN #15 Staff Development was completed. She stated, Human Resources (HR) notifies her that a new LPN has been hired. She stated the facility used an Excel spreadsheet for IV competencies. She stated whoever checks the nurse for IV competency would complete the Excel spreadsheet. She stated she could not determine by the Excel spreadsheet which LPN had training or not. RN #15 stated, in order to be completely checked off for IV competency, the LPN would have to complete the pharmacy IV course. She could not provide a response for how the facility was ensuring LPNs who were not IV trained were not performing therapy related to PICC (peripheral inserted central catheter) lines and IV ports. A PICC line is a thin, soft, long catheter (tube) that is inserted into a vein in the upper arm, leg or neck. The tip of the catheter is positioned in a large vein that carries blood into the heart. The PICC line is used for long-term intravenous (IV) antibiotics, nutrition or medications, and for blood draws, which is considered IV therapy. On 11/09/18 at 10:54 AM, an interview with RN #15 Staff Development was completed. RN #15 stated she does not have an LPN do anything hands on with a resident in regard to IV competency. She stated the training is all done in a classroom. She stated the LPN was told not do anything with IVs; a port or a PICC line until they have been IV trained through the pharmacy.",2020-09-01
2826,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2018-11-09,867,J,0,1,KBQP11,"Based on staff interview and facility policy review, the facility failed to ensure an effective quality assurance (QA) program was implemented after determining Licensed Practical Nursing (LPN) staff were performing Intravenous (IV) therapy without having IV training and verification which resulted in an Immediate Jeopardy. On 11/08/18 at 4:27 PM, the Administrator and the Director of Nursing (DON) were notified verbally that Immediate Jeopardy existed and began on 10/26/18, when Resident #58 was readmitted with a peripheral inserted central catheter (PICC). According to an audit provided by the Administrator and the DON on 11/09/18 at 8:30 AM, LPN #3, #27, #133, #156 and #177 performed IV therapy for Resident #58 and #76 without having an IV certification. This information was not addressed in QAPI (Quality Assurance and Performance Improvement). committee. Immediate Jeopardy was abated on 11/08/18 at 6:47 PM when the facility completed a full audit of all residents who had IV access that would require IV therapy. The facility revised the staffing schedule to ensure an RN or an IV certified LPN would be performing IV therapy for the four residents with IV access and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity level two (no actual harm, with potential for more than minimal harm that is not immediate jeopardy until systemic issues related to IV training and verification of LPNs. See F883 (Facility Assessment), F726 (Staff Competency) and F684 (Quality of Care) for additional information. The facility census was 128. Findings include: An interview was conducted on 11/08/18 at 11:20 AM, the staff development Registered Nurse (RN) #15 who was responsible for staff development. She stated she completed an audit on 10/03/18 regarding which LPN staff had IV training and verification. She stated she identified a number of LPN staff who were not IV trained and notified the Director of Nursing (DON) and the Administrator of the results of her audit. An interview was conducted on 11/08/18 at 12:30 PM with the Administrator and the DON. The Administrator and the DON stated they were notified of RN #15's audit regarding LPN IV training and verification. They stated they were not aware any LPNs were performing IV therapy without being IV certified. The Administrator stated the audit information had not been discussed in Q[NAME] An interview with the Regional Medical Director for the facility on 11/09/18 at 10:35 AM was conducted. She stated she does attend QA (Quality Assurance) meetings regularly. She stated she was not aware LPNs were performing IV therapy without training and verification of such. She stated this had not been discussed in Q[NAME] She stated her expectation was for nurses to be trained on the care they were providing. Although the facility identified the need for LPN IV training and competency for a number of LPN staff, the facility failed to follow through with an improvement plan to ensure LPNs were performing IV therapy with properly training. See F684, F838 and F726 for failure to ensure residents received appropriate IV therapy by a qualified staff member.",2020-09-01
2827,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2018-11-09,880,D,0,1,KBQP11,"Based on observation and interview, the facility failed to store respiratory equipment in a sanitary manner to prevent infection for one (Resident #115) of five residents who were reviewed for receiving respiratory care. The facility failed to ensure staff used proper hand hygiene to administer medications via feeding tube for one (Resident #20) of one resident administered medications via feeding tube. Findings include: 1. An observation on 11/05/18 at 12:36 PM of Resident #115's room was completed. Resident #115's respiratory equipment (nebulizer mask, tubing and machine) was observed. The nebulizer mask was lying on the resident's night stand, out of its sanitary bag (a protective bag to place the nebulizer mask and tubing in.) The nebulizer tubing was hanging down from the night stand touching the floor. An interview with Licensed Practical Nurse (LPN) #9, who cared for Resident #115 on the night shift was completed in the resident room at the time of observation on11/05/18 at 12:36 PM. LPN #9 stated, the respiratory equipment (nebulizer mask and tubing) should be kept in the sanitary bag hanging on the nebulizer machine when it's not in use. She placed the mask and tubing in the sanitary bag and left the room. An interview with LPN #156, who was caring for Resident #115 on the day shift was completed on 11/05/18 at 12:45 PM in the resident's room entrance. She stated, the nebulizer mask and tubing should be kept in its sanitary bag hanging on the nebulizer machine. She stated, the nebulizer mask would be considered contaminated if it were not cleaned after use and left out of its sanitary bag. She re-placed the mask, tubing and sanitary bag. An interview on 11/05/18 at 4:20 PM was conducted with the resident and her sister in the resident's room. Resident #115 stated she had taken off the nebulizer mask and laid it on the overbed table and fell asleep. She stated when the nurse returned, the nurse had laid it on the night stand, but it was not in the plastic bag. On 11/6/18 at 2:17 PM, an interview with the Director of Nursing (DON) was conducted in the conference room. The DON confirmed respiratory equipment such as nebulizer mask and tubing should be placed in its sanitary bag when not in use. She confirmed, if the equipment was not placed in its sanitary bag it would be an infection control concern. She stated, it could place the resident at risk for infections. The DON confirmed LPN #9 should have discarded the nebulizer mask and tubing when it was found out of its sanitary bag. 2. On 11/06/18 at 2:05 PM, licensed practical nurse (LPN) #81 was observed as she administered medication via a feeding tube to Resident #20. Upon entering the resident's room, LPN #81 set up supplies on the overbed table. Without washing her hands or using hand sanitizer, the LPN proceeded to apply gloves and administer the medication. At 2:08 PM on 11/06/18, the medication observation was reviewed with LPN #81. She acknowledged she had not washed her hands or used hand sanitizer prior to donning gloves and administering medication via the feeding tube. She stated she should have washed her hands prior to donning gloves and administering the medication. The facility's enteral medication administration policy and procedure documented: .Place supplies on a clean barrier on the bedside table .Cleanse hands. Put on gloves .Disconnect/unclamp tube as needed .",2020-09-01
2828,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-11-20,550,D,0,1,Z38K11,"Based on observation and staff interview, the facility failed to ensure Resident #69 had a dignified dining experience. This was a random opportunity for discovery during observations of the noon time meal on 11/18/19. Resident Identifier: #69. Facility Census: 127. Findings included: a) Resident #69 Observations of the noon time meal on 11/18/19 beginning at 11:55 am. found Nurse Aide (NA) #221 was standing up while feeding Resident #69 her meal. An interview with NA #221 at 12:36 pm on 11/18/19 confirmed she should not have feed Resident #69 while she was standing up. She stated, She is restorative and needs cueing and sometimes assistance and I just forgot to sit down when I started to feed her.",2020-09-01
2829,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-11-20,559,D,0,1,Z38K11,"Based on resident interview, record review and staff interview, the facility failed to provide written notification, including the reason for the change, for a facility-initiated room change for one (1) of two (2) residents reviewed for the care area of choices. Resident identifier: #94. Facility census: 127. Findings include: a) Resident #94 During an interview with Resident #94 on 11/19/19 at 8:46 AM, the resident stated that she was moved from her room to a new room and did not know why she had been moved. She stated that she had not been told why she had to change rooms. Resident #94's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/28/19 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 14. A BIMS score of 14 indicates that the resident is cognitively intact and has capacity. Moreover, a record review noted Resident #94 was deemed by a physician to have capacity on 10/23/19. During a record review, the following notes were discovered: -- 11/18/2019 16:29 Assessment Note: (RESIDENT NAME) is expected to transfer rooms on Reason for transfer: LTC Bed available 11/18/2019 Patient was notified. The patient's responsible party was notified. Roommate(s) have been notified. Asked resident to move her to LTC bed, she is ok with the move. -- 11/18/2019 10:42 Social Service Note: SW spoke with resident and son regarding discharge plans. Resident requires 24 hour care in the home with assistance with ADLs (Activities of Daily Living). Care cannot be provided in the home. Resident will transition to LTC after completing therapy. Son is working with Medicaid Advisor to help resident to qualify for Medicaid. On 11/19/19 at 11:27 AM, during an interview with Employee #96, Social Services, the surveyor asked if all beds within the facility were dually certified for both Medicare and Medicaid. SS #96 stated that all beds were dually certified. SS #96 stated that Resident #94 had a room change because she was remaining in the facility for long-term care. SS #96 stated that when an appropriate bed on the long-term care unit becomes available, the resident has to change rooms. With regard to the room change, SS #96 stated that the facility staff look at compatibility related to multi-drug resistant organisms, in order to find a compatible room. SS #96 stated that the facility explained to the family of Resident #95 that a resident cannot remain on the transitional care unit (TCU) when they become a long term care resident. SS #96 stated that the admissions department handles the room changes and looking for an appropriate roommate. SS #96 stated Resident #94's family is working on getting her Medicaid approved. On 11/20/19 at 1:10 PM, in an interview with Employee #192, Admissions Director, when a referral comes into the facility, they typically do not admit long term care residents. All referrals are for the transitional care unit (TCU). AD #192 was asked if the residents and / or their family members sign a notice or written notification that they are changing rooms. AD #192 stated the facility does not have a form or any paperwork that is given to them regarding the room change. The facility enters in a note in the resident's chart regarding the room change. On 11/21/19 at 8:28 AM, during an interview with AD #192, she again was asked if there was a form for the resident and / or family members to sign upon either admission or before the room change of notice that the resident may have to change rooms. AD #192 stated that there was not a form or written notice given, just a verbal conversation with the resident and / or family upon admission. On 11/21/19 at 8:56 AM, AD #192 came to this surveyor and stated that there is a form for notice of room change that the resident can sign. AD #192 stated that during the transition of the former employee that help the Admissions Director position and AD #192 coming into the position, the form had not been used. AD #192 stated that she began employment in (MONTH) 2019 and did not have this form. On 11/21/19 at 9:46 AM, Employee #271, Social Services and Employee #96, Social Services, spoke with Resident #94 regarding her room change. Resident #94 was questioned, with both Employee #271 and Employee #96 present, if she had been asked if she was willing to change rooms. Resident #94 stated that she had been told she was moving and that she was not asked. Moreover, Resident #94 stated that she does not like her room and she does not know her roommate. Resident #94 stated that she had never met her roommate and that they did not speak. Resident #94 stated that she misses her old room. Resident #94 repeatedly told the surveyor, SS # 271, and SS #96 she does not remember anyone asking her if she would move to a different room. Resident #94 repeatedly stated that she did not like her room and that she preferred her old room. Additionally, Resident #94 stated that she did not remember a conversation upon admission nor in her discharge planning discussions with SS #96 that she would have to change rooms if she remained in the facility for long term care. On 11/21/19 at 10:41 AM, the findings were discussed with Administrator and the Director of Nursing (DON). No further information was provided prior to end of the survey on 11/2/19 at 2:00 PM.",2020-09-01
2830,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-11-20,584,E,0,1,Z38K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and resident interview, the facility failed to maintain a clean, safe, sanitary, homelike environment for three (3) of seventy-one resident rooms within the facility. This failed practice had the potential to affect more than a limited number of residents residing at the facility. Resident identifiers: #35, #85, #112. Facility census: 127. Findings included: a) Resident #35 room [ROOM NUMBER] On 11/18/19 at 11:18 AM while standing outside of Resident's room in doorway, observation was made of very strong, fowl urine smell drifting out of Resident's room into the hallway. North Manager Registered Nurse stated the He (Resident #35) refuses to bathe and pees (urinates) in the floor. North Manager Registered Nurse entered Resident's room, opened the Residents bathroom door, stepped back and said, Yes it's (urine) in the bathroom floor. North Manager Registered Nurse stated she would have Housekeeping come get it taken care of. Yellow dried stains were also present in the Resident's floor in front of the bathroom door and at this bedside. North Manager Registered Nurse confirmed the yellow stains to be dryed urine. At 11:39 AM on 11/18/19 during an interview, Certified Nursing Assistant (CNA) #150 confirmed the Resident refused shower today and he urinates in the floor all the time. CNA #150 stated I can't pressure him or he won't shower at all, I will just go back later and ask him, he needs it, the room always smells like urine. 11/20/19 at 11:35 AM during an interview and observation of Resident #35's room, District Manager of Environmental Services #196 agreed the room smelled fowl like urine and she stated she would place this Resident's room on the Hot List for housekeeping so that it will be cleaned more frequently and thoroughly. b) Resident #85 room [ROOM NUMBER] On 11/19/19 at 9:15 AM during an interview, Resident #85 stated bathroom her room stinks and she always had to keep closed to keep the smell out of her room. Resident #85 stated her bathroom smelled like an outhouse and was due to the toilet leaking around the bottom where it was mounted to floor and not being cleaned properly. The Resident also stated the toilet seat was so loose it was dangerous and she almost falls off the toilet every time she set down on it. At 9:28 AM on 11/19/19 during observation of Resident #85's bathroom in presence of Maintenance Director (MD) #171, the toilet seat was noted to be extremely loose, almost falling off when MD #171 lifted the seat up. MD #171 was able to flop the seat sideways to both sides twisting completely around in a circle touching the wall. MD #171 stated That is bad, I ordered 12 new ones (toilet seats) and will get this one fixed right now. MD #171 agreed the bathroom smelled foul and stated he would pull the toilet up out of floor and check for a leak. MD #171 also stated he would replace the cracked missing tile in the Resident's bathroom, he has replaced it several times in other bathrooms, but Residents just keep busting it with their Wheelchairs. On 11/20/19 at 11:27 AM during an interview and observation of Resident #85's bathroom, District Manager of Environmental Services #196 agreed that the bathroom smelled terrible, like sewer and stated she would go get a scrub brush with bleach and clean around the base toilet where dark water stains were at to see if she could get the room smelling better. c) Resident #112 room [ROOM NUMBER] On 11/18/19 at 11:19 AM, Resident #112's over the bed table was found to be in very poor repair and unsanitary. The varnish (heavy plastic contact paper) was peeled away on the corners exposing compressed wood that appeared to have liquid substance stained into the pressed wood that could not be properly cleaned. The Resident stated the table had been that way for a long time and she used the table to eat her meals from every day. North Manager Registered Nurse (RN) was asked to come into Resident's room and observed the condition of the over bed table. North Manager RN agreed the over bed table was in poor repair, unsanitary and needed to be replaced. At 9:35 AM on 11/19/19 Maintenance Director #171 stated he ordered one-thousand dollars' worth of new over the bed tables to replace all the peeling disrepair tables being used and he would make sure Resident #116's table was replaced as soon as possible. e) room [ROOM NUMBER] On 11/19/19 at 9:37 AM, this surveyor entered room [ROOM NUMBER]. Before entering the room, a strong smell of urine could be smelled from outside of the resident room, slightly in the hallway. Upon entering the room, the floor was sticky from the entry door to the other side of the room. This surveyor's shoes stuck to the floor. The room had a strong smell of urine. On 11/19/19 at 9:39 AM, Employee #323, Licensed Practical Nurse (LPN) and Employee #45, LPN, entered the room. Both employees stated that they could smell a strong urine odor and the floor was very sticky, as their shoes were also sticking to the floor. LPN #45 stated that he would contact housekeeping to clean the room. On 11/19/19 at 11:59 AM, the findings were discussed with the Director of Nursing (DON) regarding the floor. The DON asked if an employee had already contacted housekeeping and was informed that Employee #45 had contacted housekeeping. On 11/21/19 at 10:41 AM, the findings were discussed with Administrator and the DON. No further information was provided prior to the end of the survey on 11/21/19 at 2:00 PM. f) Resident Council A review of the resident council minutes for the six (6) months revealed the following (copied as written): -- 9/24/19 - Patient / Resident Requests / Concerns: 100 Hall complained that at times their rooms aren't cleaned well or trash emptied - Housekeeping supervisor will address with these employees and discipline will be handed out as needed. -- 8/27/19 - Patient / Resident Requests / Concerns: Wheelchairs need cleaned, and room are not being cleaned or wax.' -- 7/23/19 - Discussion of Old / Unfinished Business: Executive Director explained about what is being done to improve cleanliness -- 7/23/19 - Patient / Resident Requests / Concerns: Resident feel that many of the rooms need stripped and waxed because even after cleaned they don't look clean. Housekeeping doesn't clean behind things and not sure they mop with clean water. Night shift are not cleaning chairs. -- 6/25/19 - Discussion of Old / Unfinished Business: Rooms still not cleaned well - When (Employee Name) and (Employee Name) are off they don't get cleaned well. -- 5/28/29 - Rooms need cleaned better, especially 100 Hall. On 11/21/19 at 10:41 AM, the findings were discussed with Administrator and the DON. No further information was provided prior to the end of the survey on 11/21/19 at 2:00 PM.",2020-09-01
2831,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-11-20,607,D,0,1,Z38K11,"Based on medical record review, resident interview, and staff interview, the facility failed to implement written policies and procedures to report and investigate allegations of abuse for one (1) of three (3) residents reviewed for care area of abuse. Resident identifier: #4. Facility census: 127. Findings included: a) Resident #4 During an interview on 11/19/19 at 8:08 AM, Resident #4 stated a nurse had yelled at him. He stated he never reported this to the facility because he didn't think it was a big deal. He did not reveal this nurse's name. Resident #4 also reported he sometimes had difficulty getting staff to change his wound dressing and getting staff to assist him into a wheelchair. He stated when his mother called the facility to report these concerns, a nurse asked him, Do you have to get your mommy to call? He revealed this nurse's name and expressed that he was upset over this statement. During an interview on 11/20/19 at 8:12 AM, the Director of Nursing (DoN) was informed of this conversation with Resident #4. She stated the facility was unaware of these situations and that she would look into the matters. Review of the facility's Policy and Procedure entitled Abuse Prohibition with effective date 07/03/13 and revision date 04/06/17 stated allegations regarding verbal abuse would be reported not later than two (2) hours after the allegation is made. The policy also stated an investigation would be initiated within 24 hours after an allegation of abuse. During a follow-up interview on 11/21/19 at 11:17 AM, the DoN stated she had spoken to Resident #4 regarding the incidents. She stated she had not yet spoken to the specific nurse named by the resident. The DoN further stated she had not reported the incidents to the State Survey Agency. No further information was provided through the completion of the survey.",2020-09-01
2832,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-11-20,609,D,0,1,Z38K11,"Based on medical record review, resident interview, and staff interview, the facility identify and report an allegation of abuse for one (1) of three (3) residents reviewed for care area of abuse. Resident identifier: #4. Facility census: 127. Findings included: a) Resident #4 During an interview on 11/19/19 at 8:08 AM, Resident #4 stated a nurse had yelled at him. He stated he never reported this to the facility because he didn't think it was a big deal. He did not reveal this nurse's name. Resident #4 also reported he sometimes had difficulty getting staff to change his wound dressing and getting staff to assist him into a wheelchair. He stated when his mother called the facility to report these concerns, a nurse asked him, Do you have to get your mommy to call? He revealed this nurse's name and expressed that he was upset over this statement. During an interview on 11/20/19 at 8:12 AM, the Director of Nursing (DoN) was informed of this conversation with Resident #4. She stated the facility was unaware of these situations and that she would look into the matters. During a follow-up interview on 11/21/19 at 11:17 AM, the DoN stated she had spoken to Resident #4 regarding the incidents. She stated she had not yet spoken to the specific nurse named by the resident. The DoN further stated she had not reported the incidents to the State Survey Agency. No further information was provided through the completion of the survey.",2020-09-01
2833,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-11-20,656,E,0,1,Z38K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, and staff interview, the facility failed to implement the individual plans of care for four (4) of twenty-seven (27) sampled residents. The facility failed to implement a care plan for Resident #57 and Resident #63 in the area of activities. The facility failed to develop a care plan for Resident #106 in the area of dental needs and / or services. The facility failed to implement a care plan for Resident #60 in the area of smoking. Resident identifiers: 57, 63, 106, and 60. Facility census: 127. Findings include: a) Resident #57 During an interview on 11/19/19 at 8:34 AM, Resident #57 stated that the facility does not have activities that he enjoys. Resident #57 stated that he would like to go on facility outings and maybe a shopping trip sometimes. Resident #57's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/01/19 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 is the highest score and indicates that the resident is cognitively intact and has capacity. Review of Residents #57's care plan found a focus/problem: While in the facility, [NAME] stated that it is important the he has the opportunity to engage in daily routines that are meaningful relative to his preferences. He has limited energy due to [MEDICAL TREATMENT]. [NAME] prefers independent activities and would like one-to-one visits for increased socialization. The goal associated with this problem: [NAME] will express satisfaction that his daily routines and preferences are accommodated by staff, satisfaction with leisure pursuits and will maintain social interactions through one-to-one visits and/or interactions in unstructured settings, through review period. Interventions included: --I would like pet visits and prefer dogs. --It is important for me to go outside when the weather is good and enjoy sitting. A review of the Activities calendars from (MONTH) 2019 to (MONTH) 2019, noted the following events: June 2019: --06/07/19 - 1:00 PM - Shopping Outing --06/28/19 - 2:30 PM - Beach Theme outdoor fun July 2019 --07/26/19 - 1:00 PM - Shopping outing August 2019 --08/23/19 - 1:00 PM - Shopping outing --08/30/19: 12:00 Pre-Labor Day celebration with an outdoor picnic September 2019 --09/20/19 - Shopping outing --09/28/19 - 10:00 AM - 2:00 PM - Fall Festival October 2019 --10/11/19 - Shopping outing November 2019 --11/08/19 - 10:00 AM - Shopping outing A record review of Resident #57's activities participation log from (MONTH) 2019 to (MONTH) 2019 noted the following: --June 2019 - There was no documentation that he had been offered and / or refused animals / pets. There was no documentation that he had been offered and refused community outings. There was no documentation that he had been offered and / or refused outside / gardening / nature tanning activities. --July 2019 - There was one day, 7/17/19, that had documentation that Resident #57 was offered and participated in animals / pets. There was no documentation that he had been offered and / or refused community outings. There was no documentation that he had been offered and / or refused outside / gardening / nature tanning activities. --August 2019 - There was one day, 8/14/19, that had documentation that Resident #57 was offered and participated in animals/pets. There was no documentation that he had been offered and/or refused community outings. There was no documentation that he had been offered and / or refused outside / gardening / nature tanning activities. --September 2019 - There was no documentation that he had been offered and / or refused animals / pets. There was no documentation that he had been offered and refused community outings. There was no documentation that he had been offered and / or refused outside / gardening / nature tanning activities. --October 2019 - There was no documentation that he had been offered and / or refused animals / pets. There was no documentation that he had been offered and refused community outings. There was no documentation that he had been offered and / or refused outside / gardening / nature tanning activities. --November 2019 - There was no documentation that he had been offered and / or refused animals / pets. There was no documentation that he had been offered and refused community outings. On 11/19/19 at 2:54 PM, the activity calendars from (MONTH) 2019 to (MONTH) 2019 with Employee #159, Activities Director. AD #159 was asked to identify the outside, shopping, and pet visits on the activities calendar. AD #159 was also asked how she documents if a resident was asked to attend an activity and they refused. AD #159 stated that the activities department does not always document when an activity is refused. AD #159 was asked if Resident #57 had been on an outing. AD #159 responded that Resident #57 had not been on an outing; he just sits in his room. AD #159 was asked when the facility offers pet visits. AD #159 stated that she typically brings her dog in every Wednesday. AD #159 stated that she does not put that on the activity calendar, since there may be times that her dog would be unable to come to the facility. During the interview, AD #159 was asked where the activities staff would document on animal / pet visits. AD #159 stated that the staff should document this activity on the Participation Record for each resident under the Animals / Pets. AD #159 stated that the activities staff does not always document animal visit participation. AD #159 stated that this is an area that her department can work on and improve. AD #159 could not provide any documentation that Resident #57 had been offered animal visits. On 11/21/19 at 10:41 AM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 11/21/19 at 2:00 PM. b) Resident #63 During an interview on 11/19/19 at 8:16 AM, Resident #63 stated that she would like to do activities, but there is nothing to do in the facility. Resident #63 stated that she does attend BINGO; however, she would to go on outings, but they have only offered her once to attend an outing and now, they staff do not offer the chance to go on outings to her. Resident #63 stated that she has only been out on an outing one (1) time. Resident #63 would like to Walmart. Resident #63 stated that she is bored a lot of times in the facility. Resident #63's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/04/19 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 14. A BIMS score of 14 indicates that the resident is cognitively intact and has capacity. Review of Residents #63's care plan found a focus/problem: Focus: While in the facility, [NAME] states that it is important that she has the opportunity to engage in daily routines that are meaningful relative to her preferences. She prefers independent activities but does little. [NAME] states an interest in several group programs but doesn't usually attend. She would benefit from reminders and encouragement to attend groups of interest as well as one-to-one visits for encouragement. Goal: [NAME] will express satisfaction that her daily routines and preferences are accommodated by staff, satisfaction with leisure pursuits and will maintain leisure pursuits, as evidenced by participation records and will maintain social interactions through one-to-one visits, once per week, through review period. Interventions include: --I would like pet visits and prefer cats and dogs but also like fish and spiders. --It is important for me to go outside when the weather is good and enjoy wildlife observing. A review of the Activities calendars from (MONTH) 2019 to (MONTH) 2019, noted the following events: June 2019: --06/07/19 - 1:00 PM - Shopping Outing --06/08/19 - 2:30 PM - Beach Theme outdoor fun July 2019 --07/26/19 - 1:00 PM - Shopping outing August 2019 --08/23/19 - 1:00 PM - Shopping outing --08/30/19 - 12:00 PM - Pre-Labor Day celebration with an outdoor picnic September 2019 --09/20/19 - Shopping outing --09/28/19 - 10:00 AM - 2:00 PM - Fall Festival October 2019 --10/11/19 - Shopping outing November 2019 11/18/19 - 10:00 AM - Shopping outing A record review of Resident #63's activities participation log from (MONTH) 2019 to (MONTH) 2019 noted the following: --June 2019 - There was no documentation that he had been offered and / or refused animals / pets. There was no documentation that he had been offered and refused community outings. There was one refusal on 6/27/19 for outside / gardening / nature tanning activities. --July 2019 - There was no documentation that she had been offered and / or refused animals / pets. There was no documentation that he had been offered and / or refused community outings. There was no documentation that he had been offered and / or refused outside / gardening / nature tanning activities. --August 2019 - There was no documentation that she had been offered and / or refused animals / pets. There was only documentation that the resident was out of the center on 8/8/19 and 8/9/19 for community outings. There was no documentation that he had been offered and / or refused outside / gardening / nature tanning activities. --September 2019 - There was no documentation that he had been offered and / or refused animals / pets. There was no documentation that he had been offered and refused community outings. There was one day, 9/7/19, where the documentation stated that Resident #63 was Independent in the activity of outside / gardening / nature tanning activities. --October 2019 - There was no documentation that he had been offered and / or refused animals / pets. There was no documentation that he had been offered and refused community outings. There was no documentation that he had been offered and / or refused outside / gardening / nature tanning activities. --November 2019 - There was no documentation that he had been offered and / or refused animals / pets. There was no documentation that he had been offered and refused community outings. There was one day, 11/17/19, where the documentation stated Resident #63 was Independent in the activity of outside / gardening / nature tanning. On 11/19/19 at 2:54 PM, the activity calendars from (MONTH) 2019 to (MONTH) 2019 with Employee #159, Activities Director. AD #159 was asked to identify the outside, shopping, and pet visits on the activities calendar. AD #159 was also asked how she documents if a resident was asked to attend an activity and they refused. AD #159 stated that the activities department does not always document when an activity is refused. AD #159 was asked if Resident #63 had been on an outing. AD #159 responded that Resident #63 had been on an outing. AD #159 stated Resident #63 now provides the staff a list and the facility staff do the shopping for Resident #63. AD #159 was asked when the facility offers pet visits. AD #159 stated that she typically brings her dog in every Wednesday. AD #159 stated that she does not put that on the activity calendar, since there may be times that her dog would be unable to come to the facility. During the interview, AD #159 was asked where the activities staff would document on animal / pet visits. AD #159 stated that the staff should document this activity on the Participation Record for each resident under the Animals / Pets. AD #159 stated that the activities staff does not always document animal visit participation. AD #159 stated that this is an area that her department can work on and improve. AD #159 could not provide any documentation that Resident #63 had been offered animal visits. On 11/21/19 at 10:41 AM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 11/21/19 at 2:00 PM. c) Resident #106 During an interview on 11/18/19 at 11:18 AM, Resident #106 stated antibiotics ate away his teeth. He stated he thought he was scheduled to see a dentist. An oral assessment completed for Resident #106 documented decayed teeth or broken teeth. Significant Change Minimum Data Set (MDS) with Assessment Reference Date 11/01/19 documented Resident #106 had obvious cavity or broken natural teeth. Review of Resident #106's comprehensive care plan revealed he used chewing tobacco. However, the care plan did not contain a focus related to dental issues. During an interview on 11/20/19 at 9:44 AM, the Director of Nursing (DoN) confirmed Resident #106's comprehensive care plan did not contain a focus related to dental issues. She stated she would add a dental focus to the care plan. No further information was provided through the completion of the survey process. d) Resident #60 An interview with Resident #60 on 11/19/19 at 11:53 a.m. confirmed he keeps his smoking supplies in his [NAME]et pocket at all times. He was sitting in the dining room and did not have his [NAME]et with him. He stated that it was in his room and his cigarettes and lighter was in his pocket of his [NAME]et. When asked how he ensures other residents don't get his smoking supplies he stated, Ain't nobody got no business in my [NAME]et. An interview with Registered Nurse (RN) #78 and RN #259 at 11:55 a.m. on 11/19/19 confirmed Resident #60 did not have any smoking supplies at the Nurses Station. They both confirmed they worked yesterday and today and Resident #60 had not asked them for smoking supplies either day. RN #259 went and spoke to the resident in the dining and asked him where his smoking supplies were and Resident #60 informed her they were in his [NAME]et in his room and he was going to smoke after he at his lunch. Both RN #259 and RN #78 confirmed Resident #60 smoked, all the time., but sometimes he does not have supplies at the desk. An interview with the Director of Nursing (DON) at 12:00 p.m. on 11/19/19 found she would not be surprised if Resident #60 kept his smoking supplies in his room because he is very non-compliant about things. She stated, I would hope he would follow the rules and give them back. She indicated after lunch she would go talk to him and get them from him. A review of Resident #60's care plan found the following focus statement: Patient may smoke independently per smoking assessment This focus statement was created on 03/25/19 by the DON. The goal associated with this practice statement read as follows: Patient will smoke safely x 90 days. This goal was initiated on 03/25/19 and a target date of 12/31/19. The interventions and goals associated with this care plan Included: -- Educate patient/health care decision maker on the facility's smoking policy -- Inform and remind patient of location of smoking areas and times -- Reassess patients ability to smoke independently with any change in condition -- Ensure that there is no oxygen use in smoking area(s). -- Ensure that appropriate cigarette disposal receptacles are available in smoking areas -- Monitor patients compliance to smoking policy -- Maintain patients smoking materials at nurses' station All interventions were added to the care plan on 03/25/19 by the DON. Observations with the DON of Resident #60 at 12:32 p.m. on 11/19/19 found the resident left the dining room and went to his room put on his [NAME]et and exited the building to the north court yard and took his cigarettes out his pocket along with his lighter and began to smoke. When Resident #60 exited the dining, the DON told him that he would have to give her his cigarettes and lighter when he was done and the resident agreed. The DON agreed the facility was not implementing Resident #60's care plan.",2020-09-01
2834,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-11-20,657,D,0,1,Z38K11,"Based upon resident interview, staff interview, and record review, the facility failed to provide notice to a resident regarding the resident's care plan meeting. This was true for one (1) of twenty-three (23) residents care plan reviewed. Resident identifier: #57. Facility census: 127. Findings include: a) Resident #57 During an interview on 11/19/19 at 8:34 AM, Resident #57 stated that he guesses that he attends care plan meetings. Resident #57's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/01/19 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 is the highest score and indicates that the resident is cognitively intact and has capacity. A record review revealed two care plan meeting notes dated 02/08/19 and 02/25/19. The care plan note for 02/08/19, revealed Resident #57's sister was in attendance. The care plan note for 02/25/19 revealed that the resident was present for the care plan meeting. A record review noted the following: -- Nurse's Note 3/5/19 17:43 - Resident was seen on this date 3/5/2019 and was evaluated by (PHYSICIAN NAME), Psychologist who found him to have capacity to make his own medial decisions. A review of Resident #57's care plan history noted that the care plan had updates the following dates: -- 10/8/2019 -- 7/10/2019 -- 4/10/2019 -- 1/15/2019 On 11/21/119 at 8:50 AM, Employee #208, Registered Nurse / Clinical Reimbursement Coordinator (RN / CRC), stated that the care plan meeting schedule is given to the receptionist to send out the invitations to the resident / family / responsible party. On 11/21/19 at 9:03 AM, Employee #79, Receptionist, stated that she delivered the care plan invitations to the residents who had capacity. Employee #79 could not find the copy of the letter for the care plan meeting in (MONTH) 2019. A review of the Careplan review schedule for (MONTH) 2019 noted the care plan meeting for Resident #57 was scheduled for Monday, 10/07/19. On 11/21/19 at 10:06 AM, RN #208 stated that she could not find a care plan note in the electronic medical record since 02/08/19. RN #208 stated that there should have been a note in the medical record for the care plan meeting. On 11/21/19 at 10:41 AM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 11/21/19 at 2:00 PM.",2020-09-01
2835,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-11-20,679,D,0,1,Z38K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview the facility failed to implement an ongoing activity program designed to meet the interests of and support the well-being of each resident. This was true for two (2) of two (2) residents reviewed for the care area of activiites. Also, the Resident Council voiced displeasure with the activities program. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #57, #63, and Resident Council. Facility census 127. Findings include: a) Resident #57 During an interview on 11/19/19 at 8:34 AM, Resident #57 stated that the facility does not have activities that he enjoys. Resident #57 stated that he would like to go on facility outings and maybe a shopping trip sometimes. Resident #57's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/01/19 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 is the highest score and indicates that the resident is cognitively intact and has capacity. Review of Residents #57's care plan found a focus/problem: While in the facility, [NAME] stated that it is important the he has the opportunity to engage in daily routines that are meaningful relative to his preferences. He has limited energy due to [MEDICAL TREATMENT]. [NAME] prefers independent activities and would like one-to-one visits for increased socialization. The goal associated with this problem: [NAME] will express satisfaction that his daily routines and preferences are accommodated by staff, satisfaction with leisure pursuits and will maintain social interactions through one-to-one visits and/or interactions in unstructured settings, through review period. Interventions included: --I would like pet visits and prefer dogs. --It is important for me to go outside when the weather is good and enjoy sitting. A review of the Activities calendars from (MONTH) 2019 to (MONTH) 2019, noted the following events: June 2019: --06/07/19 - 1:00 PM - Shopping Outing --06/28/19 - 2:30 PM - Beach Theme outdoor fun July 2019 --07/26/19 - 1:00 PM - Shopping outing August 2019 --08/23/19 - 1:00 PM - Shopping outing --08/30/19: 12:00 Pre-Labor Day celebration with an outdoor picnic September 2019 --09/20/19 - Shopping outing --09/28/19 - 10:00 AM - 2:00 PM - Fall Festival October 2019 --10/11/19 - Shopping outing November 2019 --11/08/19 - 10:00 AM - Shopping outing A record review of Resident #57's activities participation log from (MONTH) 2019 to (MONTH) 2019 noted the following: --June 2019 - There was no documentation that he had been offered and / or refused animals / pets. There was no documentation that he had been offered and refused community outings. There was no documentation that he had been offered and / or refused outside / gardening / nature tanning activities. --July 2019 - There was one day, 7/17/19, that had documentation that Resident #57 was offered and participated in animals / pets. There was no documentation that he had been offered and / or refused community outings. There was no documentation that he had been offered and / or refused outside / gardening / nature tanning activities. --August 2019 - There was one day, 8/14/19, that had documentation that Resident #57 was offered and participated in animals/pets. There was no documentation that he had been offered and/or refused community outings. There was no documentation that he had been offered and / or refused outside / gardening / nature tanning activities. --September 2019 - There was no documentation that he had been offered and / or refused animals / pets. There was no documentation that he had been offered and refused community outings. There was no documentation that he had been offered and / or refused outside / gardening / nature tanning activities. --October 2019 - There was no documentation that he had been offered and / or refused animals / pets. There was no documentation that he had been offered and refused community outings. There was no documentation that he had been offered and / or refused outside / gardening / nature tanning activities. --November 2019 - There was no documentation that he had been offered and / or refused animals / pets. There was no documentation that he had been offered and refused community outings. On 11/19/19 at 2:54 PM, the activity calendars from (MONTH) 2019 to (MONTH) 2019 with Employee #159, Activities Director. AD #159 was asked to identify the outside, shopping, and pet visits on the activities calendar. AD #159 was also asked how she documents if a resident was asked to attend an activity and they refused. AD #159 stated that the activities department does not always document when an activity is refused. AD #159 was asked if Resident #57 had been on an outing. AD #159 responded that Resident #57 had not been on an outing; he just sits in his room. AD #159 was asked when the facility offers pet visits. AD #159 stated that she typically brings her dog in every Wednesday. AD #159 stated that she does not put that on the activity calendar, since there may be times that her dog would be unable to come to the facility. During the interview, AD #159 was asked where the activities staff would document on animal / pet visits. AD #159 stated that the staff should document this activity on the Participation Record for each resident under the Animals / Pets. AD #159 stated that the activities staff does not always document animal visit participation. AD #159 stated that this is an area that her department can work on and improve. AD #159 could not provide any documentation that Resident #57 had been offered animal visits. On 11/21/19 at 10:41 AM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 11/21/19 at 2:00 PM. b) Resident #63 During an interview on 11/19/19 at 8:16 AM, Resident #63 stated that she would like to do activities, but there is nothing to do in the facility. Resident #63 stated that she does attend BINGO; however, she would to go on outings, but they have only offered her once to attend an outing and now, they staff do not offer the chance to go on outings to her. Resident #63 stated that she has only been out on an outing one (1) time. Resident #63 would like to Walmart. Resident #63 stated that she is bored a lot of times in the facility. Resident #63's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/04/19 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 14. A BIMS score of 14 indicates that the resident is cognitively intact and has capacity. Review of Residents #63's care plan found a focus/problem: Focus: While in the facility, [NAME] states that it is important that she has the opportunity to engage in daily routines that are meaningful relative to her preferences. She prefers independent activities but does little. [NAME] states an interest in several group programs but doesn't usually attend. She would benefit from reminders and encouragement to attend groups of interest as well as one-to-one visits for encouragement. Goal: [NAME] will express satisfaction that her daily routines and preferences are accommodated by staff, satisfaction with leisure pursuits and will maintain leisure pursuits, as evidenced by participation records and will maintain social interactions through one-to-one visits, once per week, through review period. Interventions include: --I would like pet visits and prefer cats and dogs but also like fish and spiders. --It is important for me to go outside when the weather is good and enjoy wildlife observing. A review of the Activities calendars from (MONTH) 2019 to (MONTH) 2019, noted the following events: June 2019: --06/07/19 - 1:00 PM - Shopping Outing --06/08/19 - 2:30 PM - Beach Theme outdoor fun July 2019 --07/26/19 - 1:00 PM - Shopping outing August 2019 --08/23/19 - 1:00 PM - Shopping outing --08/30/19 - 12:00 PM - Pre-Labor Day celebration with an outdoor picnic September 2019 --09/20/19 - Shopping outing --09/28/19 - 10:00 AM - 2:00 PM - Fall Festival October 2019 --10/11/19 - Shopping outing November 2019 11/18/19 - 10:00 AM - Shopping outing A record review of Resident #63's activities participation log from (MONTH) 2019 to (MONTH) 2019 noted the following: --June 2019 - There was no documentation that he had been offered and / or refused animals / pets. There was no documentation that he had been offered and refused community outings. There was one refusal on 6/27/19 for outside / gardening / nature tanning activities. --July 2019 - There was no documentation that she had been offered and / or refused animals / pets. There was no documentation that he had been offered and / or refused community outings. There was no documentation that he had been offered and / or refused outside / gardening / nature tanning activities. --August 2019 - There was no documentation that she had been offered and / or refused animals / pets. There was only documentation that the resident was out of the center on 8/8/19 and 8/9/19 for community outings. There was no documentation that he had been offered and / or refused outside / gardening / nature tanning activities. --September 2019 - There was no documentation that he had been offered and / or refused animals / pets. There was no documentation that he had been offered and refused community outings. There was one day, 9/7/19, where the documentation stated that Resident #63 was Independent in the activity of outside / gardening / nature tanning activities. --October 2019 - There was no documentation that he had been offered and / or refused animals / pets. There was no documentation that he had been offered and refused community outings. There was no documentation that he had been offered and / or refused outside / gardening / nature tanning activities. --November 2019 - There was no documentation that he had been offered and / or refused animals / pets. There was no documentation that he had been offered and refused community outings. There was one day, 11/17/19, where the documentation stated Resident #63 was Independent in the activity of outside / gardening / nature tanning. On 11/19/19 at 2:54 PM, the activity calendars from (MONTH) 2019 to (MONTH) 2019 with Employee #159, Activities Director. AD #159 was asked to identify the outside, shopping, and pet visits on the activities calendar. AD #159 was also asked how she documents if a resident was asked to attend an activity and they refused. AD #159 stated that the activities department does not always document when an activity is refused. AD #159 was asked if Resident #63 had been on an outing. AD #159 responded that Resident #63 had been on an outing. AD #159 stated Resident #63 now provides the staff a list and the facility staff do the shopping for Resident #63. AD #159 was asked when the facility offers pet visits. AD #159 stated that she typically brings her dog in every Wednesday. AD #159 stated that she does not put that on the activity calendar, since there may be times that her dog would be unable to come to the facility. During the interview, AD #159 was asked where the activities staff would document on animal / pet visits. AD #159 stated that the staff should document this activity on the Participation Record for each resident under the Animals / Pets. AD #159 stated that the activities staff does not always document animal visit participation. AD #159 stated that this is an area that her department can work on and improve. AD #159 could not provide any documentation that Resident #63 had been offered animal visits. On 11/21/19 at 10:41 AM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 11/21/19 at 2:00 PM. c) Resident Council During the resident council with the surveyor on 11/20/19 at 9:35 AM, the residents voiced concerns with the activities program. Resident council stated the facility only has one (1) day a month for shopping outings. Resident council stated they had requested for shopping outings to be two (2) days a month; however, they were infomed that they could not have shopping outings more than once a month. Moreover, Resident Council stated the facility staff only take them shopping at Wal-Mart, never somewhere different. The residents would like more varied options for shopping outings. Resident Council stated that they wanted more outings, and not only for shopping. Resident Council wanted to take trips outside of the facility. Resident Council stated the only activities are BINGO and puzzles. Recently, in (MONTH) 2019, a wood class was started for the male residents. A review of the Activites Calendar for the past six (6) months revealed the following: -- (MONTH) 2019: ----- 13 days of BINGO ----- 30 days of puzzles ----- 1 day of shopping ----- 1 outdoor activity (Beach theme outdoor fun) -- (MONTH) 2019: ----- 13 days of BINGO ----- 31 days of puzzles ----- 1 day of shopping -- (MONTH) 2019 ----- 14 days of BINGO ----- 31 days of puzzles ----- 1 day of shopping ----- 1 outdoor activity (Pre-Labor Day celebration with an outdoor picnic) -- (MONTH) 2019 ----- 12 days of BINGO ----- 30 days of puzzles ----- 1 day of shopping ----- 1 outdoor activity (Fall Festival 10-2: Ruff Cut Country 12-2, Petting Zoo, Food, and Fun! -- (MONTH) 2019 ----- 13 days of BINGO ----- 31 days of puzzles ----- 1 day of shopping -- (MONTH) 2019 ----- 14 days of BINGO ----- 30 days of puzzles ----- 1 day of shopping ----- 1 Men's Craft On 11/19/19 at 2:54 PM, the activity calendars from (MONTH) 2019 to (MONTH) 2019 with Employee #159, Activities Director. AD #159 was asked to identify the outside, shopping, and pet visits on the activities calendar. AD #159 was asked when the facility offers pet visits. AD #159 stated that she typically brings her dog in every Wednesday. AD #159 stated that she does not put that on the activity calendar, since there may be times that her dog would be unable to come to the facility. On 11/21/19 at 10:41 AM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 11/21/19 at 2:00 PM.",2020-09-01
2836,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-11-20,685,D,0,1,Z38K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, the facility failed to ensure proper treatment related to vision impairment for one (1) of one (1) resident in the care area of communication / sensory. Resident identifier: #63. Facility census: 127. Findings include: a) Resident #63 During an interview on 11/19/19 at 8:16 AM, Resident #63 stated that she was supposed to get her right eye operated on. Resident #63 stated that she already had her left eye operated on and was waiting on the right eye surgery appointment. A review of Resident #63's medical record revealed the following: -- 11/8/2018 10:39 Administrative Note - Appointment with (PROVIDER NAME) on 1/21/ @10:10, (AMBULANCE COMPANY) to pick up @ 9:25. MPOA (medical power of attorney) notified of appointment and time on 11/8/2018. -- 12/4/2018 16:33 General Note - Resident went OOF (out of facility) to an appointment with Eye doctor. Returned with new orders for Pre-admission testing on 12/6/18 at 8:40 AM at (PROVIDER NAME). Surgery on left eye will be on 12/7/18 and surgery on right eye will be on 12/26/18 - they will call with time 2 days in advanced. Resident is to be NPO (no food by mouth) on day of procedure; (MONTH) take routine medication in am of procedure with a sip of water. Begin using Durexol one drop one times a day in affected eye - begin two days prior to surgery - wait five minutes between drops. POA (power of attorney) aware. -- 12/6/2018 14:01 Administrative Note - Post OP (operation) appointment with (PROVIDER NAME) on 12/13/2018 @ 10:30, (AMBULANCE COMPANY) to pick up @ 9:45. MPOA notified of appointment and time on 12/6/2018. -- 12/7/2018 19:53 General Note - Resident receivec back from Eye Appt. (PROVIDER NAME); escorted by x2 (2 staff members) (AMBULANCE COMPANY) staff members. Resident with sister at bedside for Appt. Resident with new orders s/p (status [REDACTED]. Resident to f/u (follow up) as ordered. Unit clerk aware. See new orders in progress noted. -- 12/13/2018 14:02 General Note - Resident was received back to facility escorted by x 2 (AMBULANCE COMPANY) staff members. Resident had f/u with (PROVIDER NAME). Zero new orders at this time. Resident is to f/u as previously ordered. VSS. (vital signs stable) zero s/s (signs and symptoms) of distress noted. will cont (continue) to monitor. -- 12/28/2018 07:00 General Note - Verified with (PROVIDER NAME) that surgery on right eye is canceled for today. Awaiting to be rescheduled. On 11/21/19 at 8:44 AM, Employee #12, Medical Records Clerk, MRC #12 was asked if there was any documentation of an eye appointment since the 12/28/18 appointment was canceled. MRC #12 stated she did not have a record of any and could not find one, but she would ask Employee #287, Nursing Assistant (NA) since she schedules the appointments and transportation. During an interview on 11/21/19 at 10:01 AM, NA #287, she stated she had just contacted (PROVIDER NAME) regarding a follow up appointment for Resident #63. NA #287 informed the surveyor that the provider stated they had sent Resident #63 invoices several times. The provider will not see Resident #287 unit the balance of $30 has been paid. NA #287 stated that Resident #63 had not had an eye appointment since the 12/28/18 surgery had been canceled. On 11/21/19 at 10:41 AM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 11/21/19 at 2:00 PM.",2020-09-01
2837,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-11-20,689,K,0,1,Z38K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview and observation, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #60, a resident who independently smokes, was noted to keep his cigarettes and lighter in his room with him when he is not smoking. Resident #60 indicated he kept his smoking materials including his lighter in his [NAME]et pocket. The facility's policy verified all smoking materials would be locked up at the nurses desk or in the residents room. The facility's policy prohibited lighters being kept anywhere other than locked up at the nurses station. The facility identified the following residents as being confused, wandering, and rummaging residents: Resident #56, #39,#69, #92, #25, #86, #29, #79, #272, #9, #120, #78, #13, #81, #117, #23, #31, #89, #46, #118, and #116. The facility's failure to implement their smoking policy and their non-compliance to ensure the resident environment was free from accident hazards placed these 21 residents in a situation where serious injury and/or death was likely. The facility was notified of the Immediate Jeopardy (IJ) situation at 2:00 p.m. on 11/19/19. They provided a Plan of Correction (P[NAME]) at 4:28 p.m. on 11/19/19 and the P[NAME] was accepted by the state agency at 4:35 p.m. on 11/19/19. The IJ was abated at 8:50 a.m. on 11/20/19. The facility abatement plan of correction included the following. 1. Director of Nursing (DON) removed smoking supplies, including lighters, from Resident #60 possession @ 1245pm on 11/19/19. DON re-educated Resident #60 regarding the smoking policy and procedure to include all smoking materials including lighters are to be secured at 12:45 PM on 11/19/19 and resident #60 voiced understanding. Residents # 56, 39, 69, 92, 25, 29, 79, 272, 9, 120, 78,13,81, 117, 23, 31, 89, 46, 116, and 118 rooms were searched on 11/19/19 by 2:46 pm with no additional findings on the residents or in his/her resident room. 2. All residents of the facility have the potential to be affected. The DON/designee conducted rounds of all resident rooms by 2:46 pm to ensure smoking materials including lighters are secured on 11/19/19 with any corrective action immediately upon discovery. No residents have experienced any negative outcome. 3. The DON/designee will re-educate all staff including agency staff starting 11/19/19 at 3:00 PM regarding the resident environment remains free of accident hazards as is possible to include the center smoking policy to ensure that resident smoking materials including lighters are secured at all times, with a posttest to validate understanding. Staff and agency staff not available during this timeframe will be provided reeducation including posttest by the DON/designee upon day of return to work before providing care. New staff and agency staff during orientation will be provided education including posttest by the DON/designee. 4. DON/designee will monitor starting on 11/19/19 to ensure Resident smoking materials including lighters are maintained in a cabinet at nursing station across all shifts for 2 weeks, including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter to ensure that smoking materials including lighters are secured and residents who smoke follow the smoking policy. 5. Results of monitors will be reported by the DON/designee monthly at the Quality Improvement Committee (QIC) for any additional follow up and/or inservicing until the issues are resolved and randomly thereafter as determined by the QIC committee. Upon abatement of the immediate jeopardy at 8:50 a.m. on 11/20/19. The scope and severity of the deficient practice is reduced to an E. Resident identifiers: #60, #56, #39,#69, #92, #25, #86, #29, #79, #272, #9, #120, #78, #13, #81, #117, #23, #31, #89, #46, #118, and #116. Facility census: 127. Findings included: a) Resident #60 A review of Resident #60 smoking assessments dated 03/23/19, 06/24/19 and 09/24/19 verified Resident #60 was capable of smoking independently and did not need staff or family supervision while smoking. An interview with Resident #60 on 11/19/19 at 11:53 a.m. confirmed he keeps his smoking supplies in his [NAME]et pocket at all times. He was sitting in the dining room and did not have his [NAME]et with him. He stated it was in his room and his cigarettes and lighter were in the pocket of his [NAME]et. When asked how he ensures other residents don't get his smoking supplies he stated, Ain't nobody got no business in my [NAME]et. An interview with Registered Nurse (RN) #78 and RN #259 at 11:55 a.m. on 11/19/19 confirmed Resident #60 did not have any smoking supplies at the Nurses Station. They both confirmed they worked yesterday and today and Resident #60 had not asked them for smoking supplies either day. RN #259 went and spoke to the resident in the dining and asked him where his smoking supplies were and Resident #60 informed her they were in his [NAME]et in his room and he was going to smoke after he at his lunch. Both RN #259 and RN #78 confirmed Resident #60 smoked, all the time, but sometimes he does not have supplies at the desk. An interview with the Director of Nursing (DON) at 12:00 p.m. on 11/19/19 found she would not be surprised if Resident #60 kept his smoking supplies in his room because he is very non-compliant about things. She stated, I would hope he would follow the rules and give them back. She indicated after lunch she would go talk to him and get them from him. Review of the facility's smoking policy found (typed as written): --Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, etc.) will be labeled with the patient's name, room number, and bed number, maintained by the staff, and stored in a suitable cabinet kept at the nurses station. --If the patient is cognitively and physically able to secure all smoking materials, the Center may allow him/her to maintain his/her own tobacco or electronic cigarette products in a locked compartment. --Patient's will not be allowed to maintain their lighter, lighter fluid, or matches. A review of Resident #60's care plan found the following focus statement: --Patient may smoke independently per smoking assessment. This focus statement was created on 03/25/19 by the DON. The goal associated with this practice statement read as follows: --Patient will smoke safely x 90 days. This goal was initiated on 03/25/19 and a target date of 12/31/19. The interventions and goals associated with this care plan Included: --Educate patient/health care decision maker on the facility's smoking policy --Inform and remind patient of location of smoking areas and times --Reassess patients ability to smoke independently with any change in condition --Ensure that there is no oxygen use in smoking area(s). --Ensure that appropriate cigarette disposal receptacles are available in smoking areas --Monitor patients compliance to smoking policy --Maintain patients smoking materials at nurses' station All interventions were added to the care plan on 03/25/19 by the DON. Observations with the DON of Resident #60, at 12:32 p.m. on 11/19/19, found the resident left the dining room and went to his room put on his [NAME]et and exited the building to the north court yard and took his cigarettes out his pocket along with his lighter and began to smoke. When Resident #60 exited the dining room, the DON told him that he would have to give her his cigarettes and lighter when he was done and the resident agreed. The DON agreed the facility was not implementing their smoking policy or Resident #60's care plan. The following residents were identified by the facility as being confused, wandering, and rummaging residents: Resident #56, #39,#69, #92, #25, #86, #29, #79, #272, #9, #120, #78, #13, #81, #117, #23, #31, #89, #46, #118, and #116. Of the 21 residents identified as confused, wandering, rummaging residents 2 were on the 200 hall with Resident #60. There were 9 on the 100 hall which connects to the 200 hall just adjacent to Resident #60's room. The facility's failure to implement their smoking policy and their non-compliance to ensure the resident environment was free from accident hazards placed these 21 residents in a situation where serious injury and/or death was likely as a result [MEDICAL CONDITION] fire-related injuries.",2020-09-01
2838,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-11-20,695,D,0,1,Z38K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the failed to provide respiratory care within professional standard of practice. This failed practice had potential to affect only a limited number of residents and was a random opportunity for discovery. Resident identifier: #38. Facility census: 126. Findings included: a) Resident #38 On 11/18/19 at 11:25 AM, Resident #38 Oxygen Concentrator was found to be in use by the Resident via route of nasal canula at a flow rate setting of 6 liters. The Resident stated her liter flow is usually set at 3 liters for her oxygen needs. An Average Volume Assure Pressure Support (AVAP) machine (used to provide positive airway pressure ventilation at night for the treatment of [REDACTED]. The mask for the AVAP machine was in very poor repair with white pasty residue inside mask and edges of mask were busted where the mask set on the Residents face around outside seal, with pieces of plastic peeling off the cushioned portion of mask. The AVAP mask did not have a date listed on it to determine last date the respiratory supply had been changed. At 11:30 AM on 11/18/19, Registered Nurse (RN) # 109 was asked to verify the Oxygen (O2) Concentrator liter flow setting the Resident was currently using. RN #109 verified the O2 liter flow setting was on 6 liters, and that was incorrect it should be 3 liters per the physician's orders [REDACTED]. At that time the Resident stated she gotten sick in the mask the night before and vomited while using the AVAP device and identified the white residue in the mask as vomit. Record review on 11/19/19 at 4:30 PM revealed a physician's orders [REDACTED].",2020-09-01
2839,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-11-20,756,D,0,1,Z38K11,"Based on medical record review and staff interview, the facility failed to ensure the drug regimen of each resident was reviewed as least once a month by a licensed pharmacist. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #81. Facility census: 127. Findings included: Review of Resident #81's medical records revealed monthly medication regimen (MRR) reviews had been performed by the consultant pharmacist on 11/14/19, 10/08/19, 09/10/19, and 7/17/19. No MRR could be located in the medical record for the month of (MONTH) 2019. On 11/20/19 at 2:08 PM, the Director of Nursing confirmed the consultant pharmacist had not performed a MRR for Resident #81 in (MONTH) 2019. No further information was provided through the completion of the survey.",2020-09-01
2840,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-11-20,804,E,0,1,Z38K11,"Based on observations, resident interview, confidential interview, staff interview, and record review, the facility failed to provide each resident food and / or drink that was palatable, attractive, and at a safe and appetizing temperature. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 127. Findings include: a) Confidential Interview #1 On 11/19/19 at 8:16 AM, when asked how the food was, the Confidential Interview (CI) #1 stated that the food is awful. CI #1 stated that he / she orders pizza from Ginos almost everyday since he / she does not like the food. On 11/21/19 at 10:41 AM, the findings were discussed with Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 11/21/19 at 2:00 PM. CI #1 further stated that vegetables such as green beans are always served watery. b) Confidential Interview #2 On 11/19/19 at 8:34 AM, when asked how was the food, the CI #2 stated that the food is normal prison food. CI #2 stated that the food lack flavor and seasoning. CI #2 stated that the food was cold when served and many times, he / she cannot eat the meal provided. On 11/21/19 at 10:41 AM, the findings were discussed with Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 11/21/19 at 2:00 PM. c) Resident Council On 11/20/19 at 9:35 AM, during a resident council meeting with the surveyor, the residents stated that the food is always cold. Moreover, on the weekends the servings for the meals are too small. In addition, many residents stated that the food is not seasoned like should be seasoned. Also, the residents noted that most of the vegetables are mooshy and over cooked. The residents state that they do not get the items that are listed on the menu. This happens more times than they could remember. A review of the resident council minutes for the past six (6) months noted the following (copied as written): -- 10/22/19 - Patient / Resident Requests / Concerns: When trays are passed the food is often cold and evening meals are not large enough if they eat in the dining room. Meals have improved. -- 9/4/19 - Patient / Resident Requests / Concerns: Beans and meat are often not done or to tough. -- 8/27/19 - Patient / Resident Requests / Concerns: Resident's are requesting for more fresh fruit on there trays for lunch and dinner. Meal tickets need updated. -- 7/23/19 - Patient / Resident Requests / Concerns: Discussed ways that dietary is working to improve food temperatures on the floor. Dietary Manager will ensure staff passes a max of 6 plates at a time. Ordering new bottoms and dome covers for plates which they will warm up. Will test food temperatures. -- 5/28/18 - Patient / Resident Requests / Concerns: Food needs seasoned more. To much fish, would like fried bologna for lunch and the alternate as the main meal. On 11/21/19 at 10:41 AM, the findings were discussed with Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 11/21/19 at 2:00 PM. d) Test Tray On 11/20/19 at 12:54 PM, the surveyors were provided a test tray. The noon meal, as listed on the posting, was -- Philly Cheese Steak Sandwich: grilled slivered beef, American cheese, and onions on a hoagie roll. -- Garlic Tator Tots -- Shortbread Cookies The tray items presented were a steak sub, tator tots, chicken noodle coup, and 2 cookies. On the tray was also two (2) ketchup packets and two (2) packets of Zesta crackers. The meat of the sub appeared to be dry and over cooked. There was a dime-sized amount of an unknown white glob substance on one end of the sandwich. There were sporadic globs of an orange substance., that were pea-sized. The roll was soft. The chicken noodle soup contained noodles that were overcooked and mushy. The two (2) cookies were very hard and dark brown around the outer edges of the cookies. On 11/20/19 at 3:11 PM, during an interview with Employee #48, Dietary Manager (DM), DM #48 was asked if the steak sandwich contained peppers. DM #48 stated any recipe or menu item that lists ingredients as peppers, the peppers are omitted due to two (2) residents in the facility that have an allergy to peppers. DM #48 was asked what would a resident, who was not allergic to peppers, would do if they wanted peppers in their menu item. DM #48 responded that he would provide that resident with peppers on the side, if they requested peppers. DM #48 noted that the description of the lunch entree did not list peppers. DM #48 was then asked how a resident would know that peppers were available if they wanted them. DM #48 did not provide a response. On 11/20/19 at 1:08 PM, DM #48 was asked for a copy of the recipe for the philly cheese steak sandwich. On 11/20/19 at 1:15 PM, DM #48 provided the recipe for the philly cheese steak sandwich. A review of the recipe noted the following: Ingredients (for 77 servings): -- Onions, Yellow, Fresh - 2 1/3 lb -- Peppers, Green, Fresh - 3 1/10 lb -- Garlic Cloves - 1 1/2 oz -- Oil, Vegetable - 3 1/10 oz -- Pan Coating / Food Release - 1 1/2 spray -- Steak, Beef, Minute, Shaved - 13 1/10 lb -- Pepper, Black - 3/4 Tbsp -- Cheese, American, Sliced, 160 Count, .5 oz - 2 5/8 lb -- Bread, Roll, Steak - 77 each Procedures: 1. Preheat oven to 325 degrees conventional (300 degrees convection). Heat grill to medium-high. 2. Wash, trim, peel, wash, and slice onions. Wash, remove stem / seeds, wash and slice peppers into strips. Separate, peel, rinse, and finely chop garlic. Shred cheese. Cover and chill. 3. Pour small amount of oil on grill. Cook onions, peppers, garlic until onions are golden and translucent. Transfer and divide evenly to 4 deep hotel pans that has been sprayed with food release. 4. Cut steak into thin strips. Cook steak on grill with remaining oil; unit golden brown and temperature is 165 degrees for 15 seconds. Transfer and divide evenly into 4 inch deep hotel pans with vegetables. 5. Add black pepper and cheese to steak, stirring to blend. Cover and bake in oven to internal temperature of 165 degrees for 15 seconds. 6. Transfer to steamtable for service. Portion 2 oz. of meat and cheese mixture with tongs into steak roll. On 11/21/19 at 10:41 AM, the findings were discussed with Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 11/21/19 at 2:00 PM. e) Anonymous Interview #3 During an interview with Anonymous Interview #3 at 8:44 am on 11/19/19 he/she stated, the food is always cold in the mornings and I do not even like pancakes. f) Food Temperature measurements. Food temperature measurements of the breakfast meal on 11/20/19 at 8:05 am. and 8:16 am. on 11/20/19 with Cook #230 found the following temperatures: Fried Egg: 90 degrees Fahrenheit (F) Scrambled Egg: 90 degrees F Oatmeal: 118 degree F. Cook #230 stated eggs are hard to keep at temperature, but the oatmeal should have been hotter than that.",2020-09-01
2841,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-11-20,809,E,0,1,Z38K11,"Based on observations, record review, resident interview, and staff interview, the facility failed to maintain par levels for snacks on two (2) nursing unit pantries. This has the potential to affect more than a limited number of residents. Facility census: 127. a) Resident Council During the resident council meeting with the surveyor on 11/20/19 at 9:35 AM, the residents voiced that diabetic residents are having to ask for snacks. Moreover, several residents stated that they have to purchase food with their personal funds. These residents stated that they have to buy their own snacks. The residents stated that they have to keep their personal snacks in their room, because the facility does not provide snacks when the residents ask for a snack. b) South Unit On 11/20/19 at 3:28 PM, the surveyor entered the pantry on the South unit with Employee #326, Licensed Practical Nurse (LPN). The items in the pantry were: 1 cup of yoplait yogurt, one (1) full gallon of 1% milk, and one-half (1/2) gallon of chocolate milk. There were no items in the freezer and no other items present. A review of the Kitchen Prep Pantry Stock list noted that the South Pantry Par Level should be as follows: -- Milk (Chocolate, Whole, 2%) - 1 Gal (gallon) ea (each) + 16 / 8 oz Glasses -- Juice / Punch - 1 Pitcher of each -- Fruit - Assorted as Available -- Yogurt - 3 each flavor -- Pudding / Applesauce - 4 bowls & 6 / 4 oz cups of each -- Ice Cream (Strawberry, Chocolate, Vanilla, Sherbet & Itl. (Italian) Ice - 4 of each -- Margarine Packs - Small Pan -- Graham Crackers & Saltines - Full -- Salt, Pepper, Mrs. Dash - Full -- Sugar, Sugar Substitutes - Full -- Thickener Packs (Nectar & Honey) - Full -- Jelly (Regular & Sugar Free) - Full -- Ketchup, Mayo, Mustard - 1/2 full -- Oatmeal Pies, Fudge Rounds - 1 box each -- Hot Chocolate, Tea, Decaf Coffee - 5 packets -- Corn Flakes, Rice Krispies, Mini Wheats - 2 of each -- Peanut Butter Sandwich - 5 sandwiches -- Cheese Sandwich - 5 sandwiches -- Meat Sandwich - 5 sandwiches -- Chip / Pretzel / Gold fish / Cheese It's - 4 of each -- Ritz's - 1 sleeve -- Coffee Creamer - 1 can -- Bowl and Cup lids - 1/2 sleeve -- Napkins - 1 Pack -- Plastic Spoons - 24 c) North Unit On 11/20/19 at 3:35 PM, the surveyor entered the pantry on the North unit with Employee #332, LPN. The items in the pantry refrigerator were: 1 container of applesauce, one-half (1/2) gallon of chocolate milk, one (1) unopened gallon of chocolate milk, one (1) cheese sandwich, two (2) full gallons of 1% milk, one-half (1/2) gallon of chocolate milk. The items in the pantry freezer were: approximately fifteen (15) blue bunny chocolate ice cream cups. A plastic storage bin contained: three (3) bags pretzels, five (5) fudge rounds, and six (6) graham crackers. A review of the North Pantry Stock list noted that the South Pantry Par Level should be as follows: -- Milk (Chocolate, Whole, 2%) - 1 Gal (gallon) ea (each) + 16 / 8 oz Glasses -- Juice / Punch - 1 Pitcher of each -- Fruit - Assorted as Available -- Yogurt - 3 each flavor -- Pudding / Applesauce - 4 bowls & 6 / 4 oz cups of each -- Ice Cream (Strawberry, Chocolate, Vanilla, Sherbet & Itl. (Italian) Ice - 4 of each -- Margarine Packs - Small Pan -- Graham Crackers & Saltines - Compartment Full -- Salt, Pepper, Mrs. Dash - Compartment Full -- Sugar, Sugar Substitutes - Compartment Full -- Thickener Packs (Nectar & Honey) - Compartment Full -- Jelly (Regular & Sugar Free) - Compartment Full -- Ketchup, Mayo, Mustard - Compartments 1/2 full -- Oatmeal Pies, Fudge Rounds - 1 box each -- Hot Chocolate, Tea, Decaf Coffee - 5 packets -- Corn Flakes, Rice Krispies, Mini Wheats - 2 of each -- Peanut Butter Sandwich - 5 sandwiches -- Cheese Sandwich - 5 sandwiches -- Meat Sandwich - 5 sandwiches -- Chip / Pretzel / Gold fish / Cheese It's - 4 of each -- Ritz's - 1 sleeve -- Coffee Creamer - 1 can -- Bowl and Cup lids - 1/2 sleeve -- Napkins - 1 Pack -- Plastic Spoons - 24 d) Interviews On 11/20/19 at 3:14 PM, during an interview with Employee #48, Dietary Manager (DM), the dietary department keeps snacks on the halls for the Nursing Assistants (NAs) to pass out. The items in the pantries include, but are not limited to assorted chips, assorted flavors of yogurt, milk, juice, ice cream, pudding, and applesauce. The dietary department does have canned soup available for the residents who want it; however, the soup is not stored in the pantry, but rather in the dietary storage area. DM #311 stated the staff know they can come get it for a resident. Also, gingerale is kept in the storage area and the storage area is unlocked. On 11/21/19 at 10:41 AM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided prior to the conclusion of the survey on 11/21/19 at 2:00 PM.",2020-09-01
2842,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-11-20,812,E,0,1,Z38K11,"Based on observation, record review, and staff interview the facility failed to store food under sanitary conditions. There was multiple items in the freezer, walk-in cooler, and reach in cooler that were opened and not dated, and items which were still available to use past the use by date in the kitchen. This practice has the potential effect more than an isolated number of residents. Facility Census: 127. Findings Include: a) Tour of the Kitchen An initial tour of the kitchen on 11/18/19 beginning at 10:45 a.m. and concluding at 11:05 am with the Certified Dietary Manager (CDM) found the following sanitation concerns. In the walk-in freezer the following items were opened and exposed to air and was not labeled with a use by date: -- Frozen Chicken Breast [NAME]es -- Frozen Sausage [NAME]es -- Frozen Hamburger [NAME]es -- Frozen Shaved Steak -- Frozen Pulled Chicken, and -- Frozen Beef Liver. In the Walk In Cooler the following was found: -- A 5 pound container of Sour Cream which had a manufacture use by date of 10/22/19. -- Two (2) 1.25 pound bags of lettuce which were open and not labeled with a use by date. -- One (1) 5 pound bag of Mozzarella cheese which had an open date of 10/20/19. -- 25 pound box of Buffet Ham which was opened and not labeled with a use by date. -- One (1) 5 pound package of Hot Dog Wieners which were opened and not labeled with a use by date. In the reach in cooler in the Main Dining room there was an opened jar of applesauce which was not dated to indicate when it was opened, and a quart container of liquid eggs which was opened and had no date to indicate when they were opened. The CDM confirmed all the items should have been dated when opened and all items should have been discarded after the use by dates. A review of the facility's policy titled Refrigerated/Frozen Storage with an effective date of 07/01/98 with a revision date of 06/15/18 found the following pertinent information: 1. Refrigeration: 1.4 All foods are labeled with name of product and the date received and use by date once opened. Manufacture use by dates are used until opened. 2. Freezer: .2.4. Food is dated when received and with use by date when opened. Manufacture use by dates are used until opened.",2020-09-01
2843,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2019-11-20,880,D,0,1,Z38K11,"Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. During the medication administration observation, a barrier was not used between the bedside table and a multi-dose nasal spray bottle. Additionally, the indwelling urinary catheter collection bag was on the floor for one (1) of four (4) residents reviewed for the care area of catheters. Resident identifiers: #109. Facility census: 127. Findings included: a) #109 Medication administration was observed on 11/19/19 at 10:07 AM by Licensed Practical Nurse (LPN) #294 to Resident #109. Resident #109 was to receive nasal spray by a multi-dose bottle, which was kept in a box in the medication cart. LPN #294 removed the bottle of nasal spray from the box and placed it on the top of the medication cart while she prepared the resident's oral medications. Upon entering Resident #109's room, LPN #294 placed the nasal spray bottle directly on the bedside table while she administered the resident's oral medications. She then administered the nasal spray to the resident. After leaving the room, LPN #294 placed the nasal spray bottle into the box in the medication cart. LPN #294 was informed she did not use a barrier, such as a paper towel, between the bottle of nasal spray and the bedside table. This practice could transfer any infectious agents on the bedside table to the medication cart. LPN #294 had no additional information regarding the matter. No further information was provided through the completion of the survey.",2020-09-01
2844,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,558,D,0,1,EBN311,"Based on observation and staff interview the facility failed to ensure one (1) resident's call light was within reach. This was discovered during a random observation. Resident identifier: #81. Facility census: 123. Findings include: a) Resident #81 On 12/12/17 at 4:22 p.m., Resident #81 asked for her call light. Upon observation the call light was found hanging off the bedrail. It was hanging near the floor, out of reach of the resident. The resident said she had limitations on her right side and could not reach the call light. On 12/14/17 at 9:00 a.m. the Center Executive Director (CED) and the Center Nurse Executive (CNE) were informed of the resident not have access to her call light on 12/12/17.",2020-09-01
2845,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,578,D,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide treatment wishes on the Physician order [REDACTED].#278 wanted in the event of a medical emergency. This was found for one (1) of thirty-two (32) residents reviewed for Advance Directives. Resident identifier: #278. Facility census: 123. Findings include a) Resident #278 On [DATE] a review of the medical record revealed the current Physician order [REDACTED].#278. Also reviewed the Care Plan with a revision date of [DATE] had this resident with a DNR order in place. Further investigation revealed Resident #278 had a POST form dated [DATE] with Attempt Resuscitation/CPR with Comfort Measures. During an interview on [DATE] at 2:51 p.m., with Employee #4, registered nurse (RN) verified the POST form was not marked correctly to indicate the the correct Cardiopulmonary Resuscitation (CPR) wishes for Resident #278. The medical power of attorney (MPOA) wanted Do Not Resuscitate (DNR). She also reported they would contact the MPOA immediately to complete an updated POST form.",2020-09-01
2846,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,584,E,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff, the facility failed to ensure a clean, safe, comfortable environment for seven (7) out of 77 rooms. Facility census: 123. Findings include: a) On 12/14/17 at 9:00 a.m., a tour of the facility, with Maintenance Director #101 revealed the following issues: --room [ROOM NUMBER] Chairs had the finish scratched off and black marks on the floor. The heat/air conditioner unit had dirt/debris in the supply air areas. On 12/12/17 at 4:22 p.m., an observation of the ice cart on the 300 hallway, revealed the bottom two sections of the cart were covered with dirt and debris. Registered Nurse (RN) #21 was interviewed on 12/12/17 at 4:30 p.m. She said the ice carts were normally cleaned on night shift. She confirmed the cart needed cleaned. RN #21 also was shown two fabric covered chairs out the hall for resident use which had stains on the cushion/seat area. --room [ROOM NUMBER] A privacy curtain was off the hook in a few places. --room [ROOM NUMBER] The bathroom had paper towels and gloves on the floor. Gloves were also observed behind the trash can by the door. --room [ROOM NUMBER] The area beside the bed was scratched up. The heat/air conditioner unit also had broken grills. --room [ROOM NUMBER] An area under the bed had a piece of tile missing. --room [ROOM NUMBER] Broken grills observed on the heat/air conditioner unit. --room [ROOM NUMBER] Rusted tube feeding pole and the area around the pole was dirty with trash strewn around and the floor was sticky. On 12/14/17 at 9:45 a.m., Maintenance director #101, agreed all of the issues mentioned were areas that needed repaired/replaced",2020-09-01
2847,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,604,D,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview the facility failed to ensure they had developed a plan for the reduction of a physical restraint. The facility failed to ensure a physician's orders [REDACTED]. In addition they failed to ensure instructions for the correct application of the restraint were available for staff. Resident identifier: #72. Facility census: 123. Findings include: a) Resident #72 Observation, on 12/11/17 at 12:26 p.m., revealed Resident #72 had a pelvic belt in place. Resident #72 said she it was in place because she had fallen a lot. At 1:30 p.m. Registered Nurse (RN) #21 said Resident #72 was one of the higher risk residents. Licensed Practical Nurse (LPN) #6 said the resident had sustained multiple falls, had very poor safety awareness, and scoots to the end of her wheelchair. LPN #6 said that was the reason for the pelvic belt. The medical record review revealed the physical therapy initial evaluation for the restraint was on 11/01/17. On 12/12/17 at 3:40 p.m. , the physical therapist said the resident did have a clip that helped to secure the restrain in the back. According to the physical therapist the resident's roommate was releasing the clip so they had decided to use a tie method on the restraint. A review of the restraint instructions with RN #21 at 4:18 p.m. on 12/12/17 revealed the instructions available at the nurses desk included a clip which was not currently being used. RN #21 was not aware that the clip was no longer being used. Further medical record review did not reveal a plan that worked toward eventual discontinuation of the pelvic belt. The last evaluation was completed on 11/06/17. This was the date the pelvic belt was applied. The evaluation (Restraint/reduction plan) stated the restraint would be released and applied every two hours around the clock when the resident was using the wheelchair. No further reeducation plan had been attempted. On 12/13/17 at 4:28 p.m., during an interview with the CED and CNE, both had no further information regarding a plan for reduction in the restraint beyond the plan that was developed on 11/06/17. The CED stated they could start having the pelvic belt released during activities and possibly dining.",2020-09-01
2848,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,625,D,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure one (1) of one (1) residents were given the appropriate information upon transfer to the hospital. Resident identifier: #124. Facility census: 123. Findings include: a) Resident #124 On 12/14/17 at 12:54 p.m., the medical record review for Resident #124 revealed the resident was transferred to the hospital on [DATE]. The progress note dated 09/20/17 stated, Resident OOF (out of facility) at this time to (name of local hospital) via (name of ambulance company). Paperwork sent with resident. Report called to (name of local hospital) ER (emergency room ). Further review of the medical record revealed no evidence Resident #124 or their responsible party were given the necessary bed hold notice. At 1:00 p.m. on 12/14/17, the Center Nurse Executive (CNE) indicated no information could be provided to verify the facility had given the bed/hold transfer notice.",2020-09-01
2849,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,641,D,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to complete accurate assessments for three out of five residents reviewed for unnecessary medication. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #104, #64, and #83. Facility census: 123. Findings include: a) Resident #64 Review of the medical record for Resident #64 revealed the following relevant Diagnosis: [REDACTED]. Further review of the medical record for Resident #64 found the following current medications ordered: --[MEDICATION NAME] ([MEDICATION NAME]) HCI ER give 37.5 mg - 1 tablet every 24 hours for depression Further review of the current medications orders for Resident #64 found: --[MEDICATION NAME] HCI ER give 37.5 mg - 1 tablet q 24 hours for depression Review of the most recent quarterly Miniumum Data Set with an Assessment Reference Date (ARD) of 11/06/17 revealed the following: --Section I - Active Diagnoses - anxiety disorder coded --Section N - Medications - no antipsychotic, antidepressant, antianxiety medications coded On 12/13/17 at 3:34 PM, this surveyor requested documentation from the DON concerning the [DIAGNOSES REDACTED]. The DON stated she would get this information. On 12/14/17 at 7:50 AM, this information was requested again of the Administrator, and on this same date at 9:02 AM the request was made again of the DON. As of the end of the survey, no further information was provided. b) Resident #104 Record review found the following relevant and current diagnoses for Resident #104: bi-polar disorder and depression. No [DIAGNOSES REDACTED]. Further record review found active physician orders [REDACTED]. --Rameltoeon give 1 tablet 8 mg at bedtime for [MEDICAL CONDITION] --[MEDICATION NAME] Sodium tablet delayed release 250 mg - give 1 tablet by mouth 2 times a day for bi-polar AEB Unprovoked anger/throwing things --[MEDICATION NAME] 20 mg tablet once a day for depression The 14-Day MDS with an ARD of 11/27/17 revealed Section I for Active Diagnoses did not code anything for Psychiatric/Mood Disorders. Further the MDS coded Section N for Medications for antidepressant and hypnotic medications given. The care plan revealed the following: Problem: --Resident is at risk for complications related to the use of [MEDICAL CONDITION] drugs Medication:[MEDICATION NAME] dx depression, [MEDICATION NAME] for [MEDICAL CONDITION] aeb unprovoked anger/throwing things. Goal: --Resident will have the smallest most effective dose without side effects in the next 90 days. Interventions: --AIMS testing per protocol Complete behavior monitoring flow sheet Gradual dose reduction as ordered Monitor for changes in mental status and functional level and report to MD as indicated Monitor for continued need of medication as related to behavior and mood. Monitor for side effects and consult physician and/or pharmacist as needed Provide informed consent to resident or healthcare decision maker. On 12/13/17 at 02:53 PM MDS Registered Nurse (RN) #44 asked about discrepancy in the diagnoses listed in the medical record compared to the MDS assessment. No further information was provided through the end of the survey. c) Resident #83 Review of the most recent minimum data set (MDS) with an assessment reference date (ARD) 11/07/17, on 12/13/17 at 01:51 p.m., revealed the resident had multiple [DIAGNOSES REDACTED]. During the seven (7) day look back the resident was given Antidepressant and Antianxiety medication. Review of orders, on 12/13/17 at 02:52 p.m., revealed Resident #83 was ordered [MEDICATION NAME] 0.5 milligram (mg) sublingually three (3) times a day for anxiety and [MEDICATION NAME] 25 mg for depression, however no [DIAGNOSES REDACTED]. On 12/13/17 at 03:07 p.m., an interview with MDS nurse #44, agreed the MDS should have included the [DIAGNOSES REDACTED].#44 updated the MDS, after surveyor intervention, to include anxiety and depression as diagnoses.",2020-09-01
2850,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,656,E,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to develop a comprehensive care plans. Resident #72's care plan was not developed for restraint usage. Resident #83's care plan did not address interventions to treat anxiety and depression. In addition, the facility failed to implement the care plan for residents #5, #59, #46, #9, #15, and #474. For Resident #5 devices to preserve skin integrity were not in place. Resident #59's care plan was not implemented related to attendance at resident preferred activities. Resident #46's care plan was not implemented related to [MEDICAL TREATMENT] treatment. Resident #9's care plan was not implemented related to nutrition. Resident #15's care plan was not implemented related to assistive devices for skin tear prevention. Resident #474's care plan was not implemented related to activities of daily living. This was true for eight (8) of thirty-two (32) residents whose care plans were reviewed. Resident identifiers: #5, #59, #46, #9, #15, #72, #83, and #474. Facility census: 123. Findings include: a) Resident #5 Review of the resident's physician's orders [REDACTED]. Further review of the resident's care plan found the problem: (Name of Resident) is at risk for skin breakdown as evidenced by history of stage II to right buttock and at risk for the development of skin breakdown related to incontinence, generalized weakness and overall debility. The goal associated with this problem: (Name of Resident) will not develop any signs or symptoms of impaired skin integrity over the next review period. Interventions included: Prafo boots to bilateral lower extremities while in bed. Licensed nurse to remove and assess skin integrity every shift. At 3:10 p.m. on 12/12/17, observation of the resident, while in bed, with Employee #21, the Registered Nurse unit manager, found the resident was not wearing the Prafo boots as directed by the resident's care plan. The resident had been in bed for at least an hour without the boots before staff were alerted by the surveyor. At 5:10 p.m. on 12/13/17, the director of nursing (DON) said she was aware the resident was in bed on 12/12/17 and did not have the Prafo boots on. The DON confirmed she was aware the care plan was not implemented for Resident #5. b) Resident #59 Observation of the resident at various times on the following days found he was in his room in bed. The television was turned on to a cartoon channel with no volume. The room was dark and the resident had no visible activities. --12/11/17 at 12:30 p.m. --12/11/17 at 3:10 p.m. --12/12/17 at 8:48 a.m. --12/12/17 at 6:00 p.m. --12/13/17 at 8:30 a.m. --12/13/17 at 1:30 p.m. --12/13/17 at 5:10 p.m. --12/14/17 at 1:00 p.m. --12/14/17 at 3:30 p.m. Review of the resident's medical record found a [DIAGNOSES REDACTED]. Further review of the most recent minimum data set (MDS) a quarterly, with an assessment reference date (ARD) of 11/01/17, found the resident is rarely/never understood and has severely impaired cognitive skills. All activities of daily living are provided by staff. The resident is unable to get himself out of bed. All locomotion is provided by facility staff once the resident is out of bed. Review of the resident's current care plan found the problem: (Name of resident) exhibits or is at risk for limited meaningful engagement related to cognitive loss/loss of function. He has [MEDICAL CONDITION] and is non-verbal. (Name of resident) does like being around people and music. His mother likes for him to be in group activities. He likes attention. The goal associated with this problem: (Name of resident) will respond and attend to stimuli as evidenced by purposeful movement-turning in direction of the stimulus and/or gazing at stimulus and will show enjoyment, during group activity programs, through review period. Interventions included: Invite and assist (name of resident) to groups such as bingo, church, music, special events, socials, etc. when he is up to provide stimulation from having contact with others. Use props and or materials such as stuffed animals, music, noise making items, etc. that provide sensory stimulation during small sensory stimulation group. At 1:36 p.m. on 12/14/17, the activity director (AD) was asked to provide copies of the resident's activity participation log. Review of the participation records with the AD found the resident had attended bingo on only three occasions since 06/11/17. The resident had not attended any other group activities such as church services, music, socials, and special events as directed by the care plan. According to documentation on the activity participation log, sensory stimulation had been provided to the resident in his room approximately five (5) days per week. The activity director said the resident was rarely out of bed making her staff unable to bring him out to group activities. The AD verified the resident only attended 3 group activities in the past six (6) months during the interview at 1:36 p.m. on 12/14/17. The AD further confirmed the care plan was not implemented as written for the resident to attend group activities. At 3:10 p.m. on 12/14/17, the resident's nursing assistant, (NA) #111 said the television volume was never on because the remote control to the television was lost and there was no way to turn on the volume. c) Resident #46 Review of the resident's current care plan on 12/13/17 at 11:00 a.m., found the problem: Resident exhibits or is at risk for impaired renal function and is at risk for complications related to [MEDICAL TREATMENT]. The goal related to the problem was: Resident will not experience any complications related to chronic insufficiency times 90 days. Interventions included: Request pre and post weights from [MEDICAL TREATMENT] center. Further review of the, [MEDICAL TREATMENT] Communication Record, for the months of (MONTH) and December, (YEAR), found the following days when the communication record did not contain the pre and or post [MEDICAL TREATMENT] weight: --11/01/17, no post-[MEDICAL TREATMENT] weight, --11/15/17, no post-[MEDICAL TREATMENT] weight, --11/20/17, no pre-[MEDICAL TREATMENT] weight and post-[MEDICAL TREATMENT] weight, --11/22/17, no pre or post [MEDICAL TREATMENT] weight, --12/01/17, no post-[MEDICAL TREATMENT] weight, --12/06/17, no pre or post-[MEDICAL TREATMENT] weight. At 12/13/17 at 2:24 p.m., the Director of Nursing (DON) confirmed the [MEDICAL TREATMENT] center is to obtain the pre and post weights and document the information on the [MEDICAL TREATMENT] communication sheet. The DON said the facility sends the [MEDICAL TREATMENT] notebook with the resident for each treatment. The facility nurse completes the top part of the sheet and the [MEDICAL TREATMENT] center completes the bottom part of the communications sheet, which contains the pre and post-weights. If the resident returns with missing information from the [MEDICAL TREATMENT] center, the facility nurse is to call the [MEDICAL TREATMENT] center to obtain any missing information. The DON confirmed the information was missing on the above dates and confirmed she could not find the missing information. The DON was also advised the care plan required the facility to ensure [MEDICAL TREATMENT] supplied the pre and post [MEDICAL TREATMENT] weights. d) Resident #9 Review of the resident's care plan found the following problem: Resident at potential nutritional risk related to significant weight changes with no adverse effect. [DIAGNOSES REDACTED]. Mechanically altered diet due to history of pocketing. The goal associated with the problem: Resident will have no significant weight changes through next review. Interventions included: large portions all meals. At 5:30 p.m. on 12/12/17, the acting dietary manager, #78 said large portions of food were double portions. Observation of the evening meal on south hall at 6:15 p.m. on 12/12/17, found the resident did not appear to have large portions of macaroni and cheese, stewed tomatoes and mandarin oranges. Nursing assistant (NA) #26 said the portions appeared to be the same size as the other residents. The acting dietary manager, #78 provided a copy of the menu, at 6:40 p.m. on 12/12/17, which indicated one (1)cup of the macaroni and cheese would be served. Dietary Employee #78 was asked how the staff knew which scoop to use to measure out one (1) cup. He stated there should be a chart but he could not locate the chart. He said he knew he had a copy of it at home and would bring it in the next day. Observation of the resident's noon meal on 12/13/17 at 12:30 found the resident was not served large portions of pinto beans and potatoes as verified by nursing assistant (NA) #33 and dietary staff member #203. e) Resident #15 On 12/13/17 at 10:13 a.m., the medical record review for Resident #15 revealed Resident #15 had an order for [REDACTED].#21 said the resident often would kick the foot buddy off of her chair. RN #21 found the resident's blue foot buddy in the lounge area behind a chair and it appeared soiled. RN #21 said it was supposed to be in place to prevent skin tears from where the resident's legs would hit up against her chair. At 1:00 p.m. RN #27 was asked about the application of the blue foot buddy because it did not look like it was placed correctly. RN #27 looked at the device and went to get a physical therapy assistant because she was not sure how it should be applied. The physical therapy assistant observed the blue foot buddy and determined a strap was broken. A new foot buddy was applied. The resident did not rest her feet on the foot buddy. RN #27 said she would have physical therapy re-evaluate the effectiveness. The care plan review revealed the following, (Resident #15) is up on rock & go w/c (wheelchair) when OOB (out of bed daily. Ensure that her blue foot buddy on rock and go wheelchair when ou of bed. On 12/13/17 at 3:51 p.m. both the Center Nurse Executive (CNE) and Center Executive Director (CED) stated they were not sure what the device used for but knew the resident was being re-evaluated for the use of the device or a different device. f) Resident #72 Observation on 12/11/17 at 12:26 p.m., revealed Resident #72 had a pelvic belt in place. Resident #72 said she this was in place because she had fallen a lot. At 1:30 p.m. Registered Nurse (RN) #21 said Resident #72 was one of the higher risk residents. Licensed Practical Nurse (LPN) #6 said the resident had sustained multiple falls, had very poor safety awareness, and scoots to the end of her wheelchair. LPN #6 said that was the reason for the pelvic belt. A care plan review for Resident #72 revealed the resident had a care plan developed on 11/06/17 which stated, Resident is at risk for complications of restraint use of pelvic belt to wheelchair when out of bed. During an interview with Registered Nurse (RN) #44 on 12/12/17 at 4:00 p.m. it was confirmed the care plan did not address the reason for the pelvic restraint. RN #44 revised the care plan on 12/12/17 to state, (Resident #72 is at risk for complications of her pelvic belt to wheelchair, when out of bed, in an attempt to promote her safety and decreased falls/falls with injury risk. g) Resident #83 On 12/13/17 at 10:31 a.m., review of records showed resident has dementia with behaviors and experienced episodes of anxiety and depression. Review of care plan did not show person center interventions to address the resident's anxiety and depression needs. Review of orders, on 12/13/17 at 02:52 p.m., revealed Resident #83 was ordered [MEDICATION NAME] 0.5 milligram (mg) sublingually three (3) times a day for anxiety and [MEDICATION NAME] 25 mg for depression. On 12/13/17 at 03:07 p.m., an interview with MDS nurse #44, agreed the resident's care plan should have been developed to include interventions to address the resident's anxiety and depression. h) Resident #474 Resident #474 had a [DIAGNOSES REDACTED]. Resident #474's care plan included the focus, Resident/Patient is at risk for decreased ability to perform ADL(s) bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Limited mobility, dementia. An intervention was resident required supervision and set up for meals. On 12/11/17 at 1:28 p.m., Resident #474 was observed using a spoon incorrectly. He was eating chili brought in by a family member and was using the spoon with the concave side down. Resident #474's family member stated he gets confused and tries to use utensils as straws. His family member also stated she doesn't think Resident #474 gets the help he needs with eating. On 12/12/17 at 12:48 p.m., Resident #474 was observed sitting on the side of his bed with his lunch tray on the bedside table in front of him. The cover of his main entree plate had been removed. He did not appear to have eaten any of the main entree of bread with gravy and mashed potatoes. The plastic lid to his bowl of soup had not been removed. The plastic wrap over his cake had not been removed. He appeared to have drank a cup of red beverage. Resident stated he had eaten lunch. He had a trash can on his bed. On 12/12/17 at 1:01 p.m., Resident #474 was again observed sitting on the side of his bed with his lunch tray in front of him. None of his main entree was noted on his plate. Some mashed potatoes had been placed in a plastic cup on his television stand. Mashed potatoes and gravy were noted in his trash can, which had been placed on the floor on the other side of his room. The plastic lid to his bowl of soup had not been removed. The plastic wrap over his cake had not been removed. The Director of Nursing (DoN) was interviewed on 12/12/17 at 1:07 p.m. Resident #474 was in bed with his eyes closed. The DoN was shown the food in the cup on the television stand and in the trash can. She was also shown that the lid to Resident #474's bowl of soup had not been opened and the plastic wrap to his cake had not been removed. The DoN was also informed Resident #474 was observed incorrectly using a spoon the previous day. The DoN stated resident was usually able to feed himself better than he did today. She stated she would obtain a new lunch tray for the resident. She also stated she would have therapy evaluate resident. On 12/12/17 at 7:00 p.m., Resident #474 was observed sitting on the side of his bed eating dinner. Certified Nursing Assistant #19 was in his room, providing cueing and encouragement for resident to eat. A general note was written by the DoN on 12/12/17 at 7:23 p.m., stating, Therapy asked to screen resident for decline with independent dinning (sic) services, resident required more cueing at this time.",2020-09-01
2851,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,657,D,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews and staff interviews, the facility failed to revise the comprehensive care plans for two (2) of thirty-two (32) care plans reviewed. Resident #40 was no longer taking an antipsychotic medication for behaviors and Resident #123 has been attending a clinic for wound healing. Resident identifiers: #40 and #123. Facility census: 123. Findings include a) Resident #40 During a medical record review on 12/13/17 for Resident #40 it was discovered the comprehensive care plan had not been revised to indicate this resident was no longer taking the antipsychotic medication [MEDICATION NAME] for behaviors since 09/07/17. An interview on 12/13/17 at 2: 57 p.m., with Employee #4, registered nurse (RN) reported Resident #40 has not had [MEDICATION NAME] for behaviors since 09/07/17 and the care plan had not been revised to reflect this. b) Resident #123 During a medical record review on 12/11/17 for Resident #123 it was discovered the comprehensive care plan had not been revised to indicate this resident was attending a clinic for wound healing. an order for [REDACTED]. In an interview on 12/13/17 at 3:08 p.m.,with with the Employee #80, registered nurse (RN) verified the comprehensive care plan had not been revised to show Resident #123 now attends the wound clinic.",2020-09-01
2852,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,677,D,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed ensure that a resident who is unable to carry out activities of daily living (ADLs) received necessary services in the area of dining. This practice affected one (1) out of eight (8) residents reviewed for the care area of ADLs. Resident identifier: #474. Facility census: 123. Findings include: a) Resident #474 Resident #474 had a [DIAGNOSES REDACTED]. Resident #474's care plan included the focus, Resident/Patient is at risk for decreased ability to perform ADL(s) bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Limited mobility, dementia. An intervention was resident required supervision and set up for meals. On 12/11/17 at 1:28 p.m., Resident #474 was observed using a spoon incorrectly. He was eating chili brought in by a family member and was using the spoon with the concave side down. Resident #474's family member stated he gets confused and tries to use utensils as straws. His family member also stated she doesn't think Resident #474 gets the help he needs with eating. On 12/12/17 at 12:48 p.m., Resident #474 was observed sitting on the side of his bed with his lunch tray on the bedside table in front of him. The cover of his main entree plate had been removed. He did not appear to have eaten any of the main entree of bread with gravy and mashed potatoes. The plastic lid to his bowl of soup had not been removed. The plastic wrap over his cake had not been removed. He appeared to have drank a cup of red beverage. Resident stated he had eaten lunch. He had a trash can on his bed. On 12/12/17 at 1:01 p.m., Resident #474 was again observed sitting on the side of his bed with his lunch tray in front of him. None of his main entree was noted on his plate. Some mashed potatoes had been placed in a plastic cup on his television stand. Mashed potatoes and gravy were noted in his trash can, which had been placed on the floor on the other side of his room. The plastic lid to his bowl of soup had not been removed. The plastic wrap over his cake had not been removed. The Director of Nursing (DoN) was interviewed on 12/12/17 at 1:07 p.m. Resident #474 was in bed with his eyes closed. The DoN was shown the food in the cup on the television stand and in the trash can. She was also shown that the lid to Resident #474's bowl of soup had not been opened and the plastic wrap to his cake had not been removed. The DoN was also informed Resident #474 was observed incorrectly using a spoon the previous day. The DoN stated resident was usually able to feed himself better than he did today. She stated she would obtain a new lunch tray for the resident. She also stated she would have therapy evaluate resident. On 12/12/17 at 7:00 p.m., Resident #474 was observed sitting on the side of his bed eating dinner. Certified Nursing Assistant #19 was in his room, providing cueing and encouragement for resident to eat. A general note was written by the DoN on 12/12/17 at 7:23 p.m., stating, Therapy asked to screen resident for decline with independent dinning (sic) services, resident required more cueing at this time.",2020-09-01
2853,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,679,D,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide an ongoing resident centered activities program that incorporated the resident's past interests. This was true for one (1) of nine (9) residents reviewed for the care area of activities. Resident identifier: #59. Facility census: 123. Findings include: a) Resident #59 Observation of the resident at various times on the following days found he was in his room in bed. The television was turned on to a cartoon channel with no volume. The room was dark and the resident had no visible activities. --12/11/17 at 12:30 p.m. --12/11/17 at 3:10 p.m. --12/12/17 at 8:48 a.m. --12/12/17 at 6:00 p.m. --12/13/17 at 8:30 a.m. --12/13/17 at 1:30 p.m. --12/13/17 at 5:10 p.m. --12/14/17 at 1:00 p.m. --12/14/17 at 3:30 p.m. Review of the resident's medical record found a [DIAGNOSES REDACTED]. Further review of the most recent minimum data set (MDS) a quarterly, with an assessment reference date (ARD) of 11/01/17, found the resident is rarely/never understood and has severely impaired cognitive skills. All activities of daily living are provided by staff. The resident is unable to get himself out of bed. All locomotion is provided by facility staff once the resident is out of bed. Review of the resident's current care plan found the problem: (Name of resident) exhibits or is at risk for limited meaningful engagement related to cognitive loss/loss of function. He has [MEDICAL CONDITION] and is non-verbal. (Name of resident) does like being around people and music. His mother likes for him to be in group activities. He likes attention. The goal associated with this problem: (Name of resident) will respond and attend to stimuli as evidenced by purposeful movement-turning in direction of the stimulus and/or gazing at stimulus and will show enjoyment, during group activity programs, through review period. Interventions included: Invite and assist (name of resident) to groups such as bingo, church, music, special events, socials, etc. when he is up to provide stimulation from having contact with others. Use props and or materials such as stuffed animals, music, noise making items, etc. that provide sensory stimulation during small sensory stimulation group. At 1:36 p.m. on 12/14/17, the activity director (AD) was asked to provide copies of the resident's activity participation log. Review of the participation records with the AD found the resident had attended bingo on only three occasions since 06/11/17. The resident had not attended any other group activities such as church services, music, socials, and special events. According to documentation on the activity participation log, sensory stimulation had been provided to the resident in his room approximately five (5) days per week. The activity director said the resident was rarely out of bed making her staff unable to bring him out to group activities. The AD verified the resident only attended 3 group activities in the past six (6) months during the interview at 1:36 p.m. on 12/14/17. At 3:10 p.m. on 12/14/17, the resident's nursing assistant, (NA) #111 said the television volume was never on because the remote control to the television was lost and there was no way to turn on the volume.",2020-09-01
2854,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,684,D,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure two (2) of 32 residents received care in accordance with professional standards of practice, and the comprehensive person-centered care plan. Resident #124 experienced an unwitnessed fall. The facility also failed to ensure they followed physician's orders [REDACTED].#5. Resident identifiers: #124, and #5. Facility census: 123. Findings include: a) Resident #124 Medical record review, revealed a progress note dated 9/20/2017 at 9:28 a.m. The note stated, Reviewed IDT (interdisciplinary team) note on 9/19/17 @ (at) 5PM (5:00 p.m.) resident was found on floor in front of bathroom door, states she lost her balance and fell , neuro initiated, area clear of clutter, non skid socks in use, Np (nurse practitioner) in notified with new orders for CBC (complete blood count), BMP (basic metabolic profile), TSH ([MEDICAL CONDITION] stimulating hormone), resident was assessed yesterday after fall by Np noted to have congestion without cough, X-ray pending at this time, nebs and oxygen ordered as well, oxygen sat every shift as well, failed GDR (gradual dose reduction) in Aug for [MEDICATION NAME], improvement noted with med changes, care plan reviewed and updated. A review of the neurological assessment policy revealed after an unwitnessed fall neurological assessments would be performed as follows: Every 30 minutes for two (2) hours, then every one (1) hour for four (4) hours, then every four (4) hours for 24 hours. The neurological assessment flow sheet for Resident #124 revealed the facility completed neurological assessments for on 09/19/17 at 5:00 p.m., 5:30 p.m., 6:00 p.m., 8:00 p.m. On 09/20/17 neurological assessments were completed at 9:00 p.m., 1:00 a.m., 5:00 a.m., 8:00 a.m., and 12:00 p.m. According to the policy neurological assessments should have been completed on 09/19/17 at 5:00 p.m., 5:30 p.m., 6:00 p.m., 6:30 p.m., 7:00 p.m., 8:00 p.m., 9:00 p.m., 10:00 p.m., 11:00 p.m., 3:00 a.m., 7:00 a.m., 12:00 p.m. The resident was transferred out of the facility to a local hospital after 12:00 p.m. on 09/20/17. The Center Nurse Executive (CNE) was interviewed, at 1:00 p.m. on 12/14/17, regarding the neurological assessments. She provided no further evidence that these assessments were performed as the policy had indicated they should have been. b) Resident #5 Review of the resident's physician's orders [REDACTED]. Further review of the resident's care plan found the problem: (Name of Resident) is at risk for skin breakdown as evidenced by history of stage II to right buttock and at risk for the development of skin breakdown related to incontinence, generalized weakness and overall debility. The goal associated with this problem: (Name of Resident) will not develop any signs or symptoms of impaired skin integrity over the next review period. Interventions included: Prafo boots to bilateral lower extremities while in bed. Licensed nurse to remove and assess skin integrity every shift. At 3:10 p.m. on 12/12/17, observation of the resident, while in bed, with Employee #21, the Registered Nurse unit manager, found the resident was not wearing the Prafo boots. The resident had been in bed for at least an hour without the boots before staff were alerted by the surveyor. At 5:10 p.m. on 12/13/17, the director of nursing (DON) said she was aware the resident was in bed on 12/12/17 and did not have the Prafo boots on.",2020-09-01
2855,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,687,D,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure Resident #118 received proper care and services to maintain her toe nails in good condition. This practice affected one (1) of eight (8) residents reviewed for the care area of activities of daily living. Resident identifier: #118. Facility census: 123. Findings include: a) Resident #118 Upon observation on 12/11/17 at 1:45 p.m., Resident #118 was noted to have a long toe nail on the great toe of her left foot. The toe nail was yellow and thickened, and protruded over her toe toward the lateral side of her foot. Resident #118 received a dressing to her left heel three times a day. The dressing change by Licensed Practical Nurse (LPN) #104 was observed on 12/13/17 at 3:00 p.m. During the dressing change, LPN #104 was questioned regarding podiatry care for Resident #118. LPN #104 stated a podiatrist makes scheduled visits to the facility, and [MEDICATION NAME] residents who are on a list to be seen by him. She stated she didn't know if Resident #118 was scheduled to see the podiatrist during his next visit. LPN #104 stated she would make sure Resident #118 was added to the list of residents to be seen by the podiatrist, if she wasn't on the list already. During an interview on 12/13/17 at 3:58 p.m., the Director of Nursing (DoN) stated she thought Resident #118 had been seen by the podiatrist during his last visit on 11/29/17. The DoN stated she would confirm this. On 12/13/17 at 4:30 p.m., the DoN stated the podiatrist had not seen Resident #118 on 11/29/17. On 12/13/17, the DoN obtained a telephone order from the attending physcian for a podiatry consult.",2020-09-01
2856,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,689,D,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and medical record review the facility failed to ensure they maintained an area for residents that was as free from accident hazards as possible. This affected two (2) out of nine (9) residents reviewed for the care area of accidents and one (1) resident whose room was part of a random observation during the initial screening process. Room Number: 317. Resident identifiers: #5, and #58. Facility census: 123. Findings include: a) room [ROOM NUMBER] On 12/11/17 12:09 p.m., an electrical outlet cover in room [ROOM NUMBER] room found the outlet cover was not secured to the wall. Maintenance Assistant #97 observed the outlet cover on 12/11/17 at 12:30 p.m. He stated the resident's bed rail had caught on this outlet cover and caused it to become loose. He verified this outlet covered needed secured to the wall. b) Resident #5 Observation of the resident at 1:50 p.m. on 12/11/17, found the resident had dark purple bruising around both eyes and bruising on her forehead. Further review of the facility's risk management system found the resident fell at the facility on 12/03/17. The resident was observed on the floor beside the bed, laying on the right side with her head near the dresser. The resident sustained [REDACTED]. The resident was sent to a local hospital after the fall. The hospital emergency department report noted the resident had a large hematoma on the right forehead as well as a smaller scalp hematoma on the left side. The hospital noted the resident, Is severely Kyphotic and Scoliotic [MEDICAL CONDITION](cerebral vascular incident), contracture of extremities as well as the spine and unable to lay down for any CT imaging The resident's condition was discussed with her son who wanted comfort measures. Respecting her wishes of comfort measures patient will be discharged back to nursing home with comfort care orders The resident's care plan addressing falls was updated on 12/04/17, with an intervention to move the dresser away from resident's bed to prevent any injuries with falls. Observation of the resident's room at 3:10 p.m. on 12/12/17, with Registered Nurse (RN) #21 found the dresser had been moved from the resident's right side of the bed. RN #21 said it was suspected the resident hit her head on the dresser when she fell . A moveable, wooded, wardrobe with drawers remained on the resident's left side of the bed. The resident had fall mats at each bedside. The fall mat on the left side of the bed extended about 2 feet beyond the footboard of the bed, due to the wardrobe located beside the head of the bed. RN #21 said she did not know why the wardrobe was not moved but she would have maintenance move the wardrobe to the wall across from the foot of the resident's bed. The above situation was discussed with the director of nursing (DON) at 5:15 p.m. on 12/12/17. No further information was provided by the facility. c) Resident #58 Record review found the resident fell at the facility on 11/20/17. The risk management system document described the circumstances of the event as: The aide was assisting the resident to the bathroom. The Resident attempted to stand on her own and fell on the right side. No injuries were received. Review of the current care plan found the problem: (Name of Resident) has potential for sustaining injuries from falls due to her prior history of falls with injury, decreased mobility, current medication regime, generalized weakness and de conditioned state. The goal associated with the problem was: (Name of Resident) will not have any falls with injury resulting in an emergency room visit through next evaluation. Interventions included: On 11/21/17, an intervention for two (2) staff members to assist the resident when using the toilet was added to the care plan. Review of the minimum data set (MDS) with an assessment reference date (ARD) of 10/17/17, an annual assessment, noted the resident requires extensive assistance of two staff members for toilet use. Toilet use is described as how the resident uses toilet room, commode, bedpan or urinal, transfers on/off toilet, cleanses self after elimination, etc. At 4:23 p.m. on 12/12/17, the Director of Nursing (DON) said at the time of the fall, the resident only required one (1) staff member to assist with toileting. The DON said the 10/19/17 MDS was correct that two (2) staff members had assisted with toileting during the look back period but since two (2) staff members did not have to always assist the resident, the number of staff needed for toileting was not changed from one (1) to two (2) until after the fall on 11/20/17. At 4:56 p.m. on 12/12/17, the Registered Nurse (RN) # 44 provided documentation her MDS was correct when completed on 10/19/17. RN #44 said the resident was in therapy from 10/11/17 until 10/31/17 and therapy did not recommend two staff members for assistance. Review of the therapy summary of care found the resident met goals for minimal assistance with transfers but can be inconsistent due to her cognition and attention to task. Patient does require redirection to task often and in closed, quiet room patient does better with transfers and participation. RN #44 said the MDS is not used to determine the amount of assistance needed for transfers. RN #44 was asked to provide information regarding how the facility determines the assistance needed for ADL's. At the close of the survey on 12/14/17 at 5:00 p.m. no further information was provided. The facility was aware or should have been aware, the resident required two person assist for toileting during the look back period for the 10/19/17 MDS. The amount of staff assistance, from one (1) to two (2) was increased only after the resident fell while toileting with only 1 nursing assistant.",2020-09-01
2857,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,692,D,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure Resident #46, who receives [MEDICAL TREATMENT], received the therapeutic diet as ordered by the physician. This was true for one (1) of eight (8) residents reviewed for the care area of nutrition. Resident identifier: #46. Facility census: 123. Findings include: a) Resident #46 Review of the residents' physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. The order was obtained on 11/15/17. Observation of the evening meal in the South dining room, began at 5:29 p.m. on 12/13/17. Resident #46 was seated in the dining room. The main course was macaroni and cheese, and stewed tomatoes. The substitute meal was lemon herb chicken and rice. The resident received a bowl of tomatoes and macaroni and cheese from dietary employee #123 serving food for the south dining room. Review of the resident's meal ticket used to prepare her tray, found the resident was to receive a regular/liberalized diet with large portions. Employee #84, a licensed practical nurse (LPN) verified the resident received and ate a bowl of tomatoes. LPN #84 also did not believe #46 did not have a large portion of macaroni and cheese- considered to be the residents meat serving. LPN #84 said Resident #46 received the same serving of macaroni and cheese as the other residents. At 5:36 p.m., on 12/12/17, the acting dietary manager said he would have to correct the resident tray ticket to include the foods she was not to be served due to her end stage [MEDICAL CONDITION]. The acting dietary manager, #78 provided a copy of the menu, at 6:40 p.m. on 12/12/17, which indicated one (1)cup of the macaroni and cheese would be served. Dietary Employee #78 was asked how the staff knew which scoop to use to measure out one (1) cup. He stated there should be a chart but he could not locate the chart. He said he knew he had a copy of it at home and would bring it in the next day. On 12/13/17 at 9:00 a.m., Dietary Employee #78 provided a copy of the scoop size chart. The chart reflected that a number eight (8) scoop equaled a measure of 1/2 cup. Dietary Employee #78 agreed the residents who were served food from the south dining area did not receive enough macaroni and cheese at the evening meal on 12/12/17.",2020-09-01
2858,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,695,D,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interviews the facility failed to ensure that appropriate emergency supplies were present at the bedside of resident with a [MEDICAL CONDITION]. This was true for one (1) of one (1) residents reviewed for the area of [MEDICAL CONDITION] care. This practice had the potential to affect all residents with a [MEDICAL CONDITION]. Resident identifiers: #17. Facility census: 123 Findings include: a) Resident #17 Observation of bedside emergency supplies for Resident #17's [MEDICAL CONDITION], on 12/12/17 at 09:45 a.m. with License Practical Nurse (LPN#13), revealed no ambu bag (manual resuscitation bag) available bedside. LPN#13 stated the ambu bag was on the crash cart. Review of the last quarterly minimum data set (MDS) with an assessment reference date (ARD) 09/25/17, on 12/12/17 at 01:04 p.m., revealed Resident #17 Brief Interview for Mental Status (BIMS) reveals a cognitive status score of fifteen (15) indicating the resident is cognitively intact. The resident needs extensive assistance with her activities of daily living (ADLs). The resident receives special treatments and procedures that includes respiratory treatments, [MEDICAL CONDITION] care, suctioning, and oxygen (O2). Pertinent [DIAGNOSES REDACTED]. On 12/12/17 at 02:31 p.m., review of the facility's policy on [MEDICAL CONDITION] emergency bedside supplies revealed that all [MEDICAL CONDITION] patient will have emergency supplies kept at the bedside. Nursing is responsible for maintaining the supplies. The purpose is to assure necessary supplies are available at the bedside in the event of a respiratory emergency. Practice standards stated under 1.3 Manual resuscitation bag with any necessary connectors to fit patient's [MEDICAL CONDITION]. Interview with Respiratory Therapist, RT#300, on 12/13/17 at 10:43 a.m. revealed there is supposed to be an ambu bag bedside. RT#300 stated she had originally placed it bedside herself when resident was admitted , and did not know what had happened to it. RT#300 confirmed it is part of the emergency supplies that needed to always be bedside. An anbu bag was placed bedside after surveyor intervention.",2020-09-01
2859,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,697,E,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to consistently evaluate the effectiveness of an as needed (PRN) pain medication for Resident #46 to determine if the residents pain was controlled after administration of the medication. In addition, the facility failed to consistently provide non-pharmacological interventions before administering the pain medication. This was true for one (1) of three (3) Residents reviewed for the care area of pain. Resident identifier: #46. Facility census: 123. Findings include: a) Resident #46 At 8:38 a.m. on 12/12/17, the resident said she frequently has pain in her hips. She said she gets pain medication but it doesn't always help. The resident's last brief interview for mental status (BIMS), completed with the quarterly minimum data set (MDS) with an assessment reference date (ARD) of 10/20/17, noted the resident was cognitively intact. Review of the December, (YEAR), Medication Administration Record [REDACTED]. Review of the MAR found the resident received the PRN [MEDICATION NAME] every day in December. The facility provided a copy of the PRN Pain Management Flow Sheet, for December, (YEAR). The form required licensed nurses to rate the resident pain, document the non-pharmacological interventions provided, the location of the pain and the pain rating after the resident received the medication. On the following days and times the resident received the medication without evidence of non-pharmacological interventions, pain rating before and after administration of the medication, and the location of the resident's pain. --12/01/17 at 10:00 p.m. --12/02/17 at 5:00 a.m. and 10:00 p.m. --12/03/17 at 5:00 a.m., 9:00 a.m. and 9:00 p.m. --12/04/17 at 6:00 a.m. and 9:00 p.m. --12/05/17 at 5:00 a.m., 10:00 a.m. and 10:00 p.m. --12/08/17 at 5:00 a.m. and 9:00 p.m. --12/09/17 at 5:00 a.m. and 9:00 a.m. --12/10/17 at 5:00 p.m. 5:00 a.m., 8:00 p.m. --12/11/17 at 1:00 a.m., 5:00 a.m., 10:00 a.m. and 10:00 p.m. At 8:35 a.m. on 12/14/17, the Director of Nursing (DON) confirmed the facility was unable to find documentation to support evidence of non-pharmacological interventions, pain rating before and after administration of the medication, and the location of the resident's pain on the above dates and times when nurses administered [MEDICATION NAME]. Review of the facility's Pain Management Policy, revised on 11/28/16, found, .If PRN medications are given, document on the back of the MAR indicated [REDACTED]. Patients receiving interventions for pain will be monitored for the effectiveness and side effects in providing pain relief Document: Effectiveness of PRN medications .",2020-09-01
2860,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,698,E,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure ongoing assessment and oversight of Resident #46 before and after [MEDICAL TREATMENT] treatments. Consistent communication between the facility and the treatment center was not available regarding the resident's pre and post [MEDICAL TREATMENT] weights. This was true for one (1) of one (1) resident reviewed for the care area of [MEDICAL TREATMENT]. Resident identifier: #46. Facility census: 123. Findings include: a) Resident #46 Review of the resident's current care plan on 12/13/17 at 11:00 a.m., found the problem: Resident exhibits or is at risk for impaired renal function and is at risk for complications related to [MEDICAL TREATMENT]. The goal related to the problem was: Resident will not experience any complications related to chronic insufficiency times 90 days. Interventions included: Request pre and post weights from [MEDICAL TREATMENT] center. Further review of the, [MEDICAL TREATMENT] Communication Record, for the months of (MONTH) and December, (YEAR), found the following days when the communication record did not contain the pre and or post [MEDICAL TREATMENT] weight: --11/01/17, no post-[MEDICAL TREATMENT] weight, --11/15/17, no post-[MEDICAL TREATMENT] weight, --11/20/17, no pre-[MEDICAL TREATMENT] weight and post-[MEDICAL TREATMENT] weight, --11/22/17, no pre or post [MEDICAL TREATMENT] weight, --12/01/17, no post-[MEDICAL TREATMENT] weight, --12/06/17, no pre or post-[MEDICAL TREATMENT] weight. At 12/13/17 at 2:24 p.m., the Director of Nursing (DON) confirmed the [MEDICAL TREATMENT] center is to obtain the pre and post weights and document the information on the [MEDICAL TREATMENT] communication sheet. The DON said the facility sends the [MEDICAL TREATMENT] notebook with the resident for each treatment. The facility nurse completes the top part of the sheet and the [MEDICAL TREATMENT] center completes the bottom part of the communications sheet, which contains the pre and post-weights. If the resident returns with missing information from the [MEDICAL TREATMENT] center, the facility nurse is to call the [MEDICAL TREATMENT] center to obtain any missing information. The DON confirmed the information was missing on the above dates and confirmed she could not find the missing information.",2020-09-01
2861,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,761,E,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy and procedures review, and staff interview, the facility failed to maintain a system of medication storage to ensure accurate reconciliation of all expired and/or discontinued medications by: (a) failing to dispose of medications in a timely manner for four (4) residents who were no longer residing in the facility and for seven (7) active residents who had medications discontinued by physician's orders [REDACTED]. This system failure had the potential to affect all residents on South Hall. Resident identifiers: #25, #37, #45, #46, #47, #424, #425, #426 and #427. Facility census: 123. Findings includes: On 12/14/17 at 10:00 am, Employee #21, Director of Nursing (DON) was present during the inspection of discontinued medications, stored in an unlocked base cabinet, in the medication room located on South Hall. Employee #21, DON stated, the night shift completes the inventory of the discontinued medications. Since we use Omniview to process medication returns to the pharmacy, the nurse scans the bar code on the product label or enters the prescription number. The pharmacy will pick the medications up once we send the list of the returned medications to the pharmacy. Twenty-four (24) oral medications, two (2) nebulizer medications, six (6) intravenous (IV) medications and three (3) vials of [MEDICATION NAME] Omnicell were not returned to the pharmacy in a timely manner and/or destroyed by the Pharmacist and Licensed Nurse, per facility's pharmacy policy and procedure. The quantity of discontinued oral medications included: --Resident #25: [MEDICATION NAME] 200 mg/1 ml vial: one (1) vial --Resident #37: [MEDICATION NAME] HCl 10 mg capsule: thirty (30) capsules; Duloxetine HCl 20 mg cap DR: twenty-one (21) capsules; and [MEDICATION NAME] HCl 4 mg tab: one (1) tablet --Resident #45: Benzonate 100 mg capsule: sixty-three (63) capsules and Duloxetine HCl 60 mg capsule DR: thirty-two (32) capsules --Resident #46: Aripiprazole 15 mg tablet: forty-five (45) tablets and [MEDICATION NAME] F/C 800 mg tablet: thirty (30) tablets --Resident #47: [MEDICATION NAME] 100 mg capsules: thirty (30) capsules and Ropinirole HCl 1 mg tablet: thirty (30) tablets --The quantity of discontinued oral medications for discharged residents included: --Resident #424: [MEDICATION NAME] 100 mg tablet: twenty-seven (27) tablets; [MEDICATION NAME] 8 mcg capsule: six (6) capsules; [MEDICATION NAME] HBR F/C 20 mg tablet: thirty-five (35) tablets; Eliquis 2.5 mg tablet: eighteen (18)) tablets; [MEDICATION NAME] 100 mg capsules: eleven (11) capsules; [MEDICATION NAME]-[MEDICATION NAME] UD 0.5-3mg/3 [MEDICATION NAME] Neb: twenty-four (24) [MEDICATION NAME]; [MEDICATION NAME] F/C 25 mg tablet: thirteen (13) tablets; [MEDICATION NAME] Sodium 50 mcg tablet: fifteen (15) tablets; [MEDICATION NAME] Mono-Macro 100 mg capsules: thirty-eight (38) capsules; NAME] 20 mg tablet DR: forty-eight (48) tablets; [MEDICATION NAME] 300 mg tablet: eleven (11) tablets; [MEDICATION NAME] F/C 0.25 mg tablet: fifty-five (55) tablets; [MEDICATION NAME] F/C 20 mg tablet: fifteen (15) tablets; --Resident #425: [MEDICATION NAME]/[MEDICATION NAME] 25-100 mg tablet: one-hundred and thirty-five (135) tablets; --Resident #426: Carvedilol 0.125 mg tablet: thirty (30) tablets Expired medications to be destroyed by the Pharmacist and Licensed Nurse: --Resident #427 [MEDICATION NAME] six (6) 100 ml IV bags --Stock Medication: [MEDICATION NAME] Omnicell replacement three (3) vials It was noted the dispensing dates the medications for the discharged residents were dated (MONTH) and (MONTH) (YEAR); July, September, (MONTH) and (MONTH) (YEAR). Policy review of 8.1 Medication Returns to Pharmacy and Credits effective date 08/01/02, revision date 03/01/11 states: Purpose: to provide a system of inventory control and security for medications to be returned to the pharmacy. Process 6. For Centers using Omniview to process medication returns to the pharmacy, the authorized Omniview user or delegate: 6.1 Scans the bar code of the product label or enters the prescription number in the box provided; 6.2 Enters the quantity of each medication to be returned to the pharmacy; 6.3 Prints two copies of the Receipt for Returned Products to: 6.3.1 Send to the pharmacy with the returned medications, and 6.3.2 Retain in the Center for billing reconciliation. Process 7. Center securely stores medications to be returned to the pharmacy until they are picked up by the pharmacy driver. Additionally, review of policy 8.2 Disposal/Destruction of Refused, Discontinued, and Expired Medications, effective date 08/01/02, revision date 03/01/11 states: Purpose: To safely, legally, and properly dispose of all refused, outdated, or unwanted, non-controlled drugs. To ensure that medications waiting to be destroyed are stored and secured properly. Process 2. For Outdated or Discontinued Medications in Packaging from Pharmacy: 2.1 If destruction cannot occur immediately, outdated or discontinued medications in packaging from the pharmacy are stored in a double-locked cabinet/drawer/area until such time as destruction can occur. Process 6. For Centers using Omnicare, Inc. Omniview to process records of product destruction, the authorized Omniview user (or delegate): 6.1 Scans the bar code of the product label or enters the prescription number in the box provided; 6.2 Enters the quantity of each medication to be destroyed; 6.3 Prints the Record of Product Destruction for inventory reconciliation and retains a copy in the Center per regulation. The Receipt for Returned Products listed above was not completed until 12/14/17 at 11:02 am.",2020-09-01
2862,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,803,E,0,1,EBN311,"Based on observation, and staff interview the facility failed to ensure menus were followed. The proper portions of macaroni and cheese were not served at the dinner meal. This had the potential to affect all residents who received their meal from the North and South dining area. Facility census: 123. Findings include: a) On 12/12/17 at 6:30 p.m., during an observation Resident #80, who was eating her dinner in her room, had a small portion of macaroni and cheese. Macaroni and cheese was served with a bowl of tomatoes and a piece of bread. Macaroni and cheese was considered the main entree for the meal. An interview with Dietary Employee #123, on 12/12/17 at 6:33 p.m., revealed she used one #10 scoop to serve the macaroni and cheese. An interview with Dietary Employee #201, at 6:38 p.m. on 12/12/17, revealed she used one #6 scoop to serve the macaroni and cheese. Dietary Employee #78 provided a copy of the menu, at 6:40 p.m. on 12/12/17, which indicated one (1)cup of the macaroni and cheese would be served. Dietary Employee #78 was asked how the staff knew which scoop to use to measure out one (1) cup. He stated there should be a chart but he could not locate the chart. He said he knew he had a copy of it at home and would bring it in the next day. On 12/13/17 at 9:00 a.m., Dietary Employee #78 provided a copy of the scoop size chart. The chart reflected that a number eight (8) scoop equaled a measure of 1/2 cup. A #10 scoop measured 1/3 cup. A #6 scoop measured 2/3 cup. Dietary Employee #78 agreed the residents who were served food from the south dining area did not receive enough macaroni and cheese and the residents who received their meal from the north dining area received more than they should have at the evening meal on 12/12/17.",2020-09-01
2863,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,804,E,0,1,EBN311,"Based on observation, confidential resident interviews and staff interview the facility failed to ensure the food served to residents was appetizing, palatable and served at the proper temperature. Residents complained about the taste, and appearance and temperature of the food served. Observations at two (2) different meals revealed the food was not served at the proper temperature. This had the potential to affect all residents who were served food from the kitchen. Facility census: 123. Findings include: a) A confidential resident interview on, 12/11/17 at 2:41 p.m., revealed a resident who had sustained a weight loss. This resident's care plan revealed a focus area which stated, Resident is a potential nutrition risk r/t (realted to) sig. (significant) weight losses, loss trend. This resident complained that the food was not good. She said she really would prefer just to have pork and beans and macaroni and cheese. On 12/12/17 at 6:30 p.m., the resident was served macaroni and cheese but did not like it because it, didn't have enough cheese. b) During the resident council meeting, on 12/12/17 at 10:30 a.m., residents complained about the taste of the food served. They said it did not taste very good. They indicated the food had poor taste and did not look appetizing. One (1) resident said the meats that were served including turkey were usually dry. A review of the council minutes revealed the residents companied about the food in July. They had said they dietary staff did not follow the preferences and dislikes and that they did not have enough alternatives for food they did not like. c) Palatable and appetizing Observation of the noon meal on the South dining room found the meal served was Bean and Bacon soup with crackers, tuna salad sandwich on wheat, pasta salad, or pepperoni calzone. Several residents had selected the pepperoni calzone. The calzone was over baked and difficult for residents to cut. The dietary staff member, E#123 serving the meal, was asked if she had any calzones that were not burnt by a resident. [NAME] #123 replied, No. Observation of the evening meal at 5:36 p.m. on 12/12/17, in the south dining room found the main meal was deluxe macaroni and cheese, (described as tender elbow macaroni baked in a creamy cheddar, American, Swiss and parmesan cheese sauce and topped with buttery seasoned bread crumbs), and stewed tomatoes. Lemon basil chicken baked in a creamy lemon and basil sauce with yellow rice was the substitute. At 5:36 p.m. on 12/12/17, the kitchen employee, #123 was asked about the creamy white sauce for the chicken. [NAME] #123 said I don't know why we don't have any, you will have to ask the manager. Several residents in the South dining area were complaining about the macaroni not being prepared as they would like. Residents expressed there was no cheese in the macaroni and they believed the macaroni should have been prepared with yellow cheese. At 6:00 p.m. on 12/12/17 the acting food service supervisor, employee #78 was interviewed regarding the meal. [NAME] #78 said there was no creamy lemon and basil sauce. He said the chicken was brushed with mayonnaise, lemon and spices before baking. He confirmed the description posted on the menu indicated a creamy sauce was being served with the chicken. E#78 said the macaroni was prepared with mozzarella cheese and that was why the macaroni wasn't yellow. The posted menu noted the macaroni and cheese was prepared with creamy cheddar, American, Swiss and parmesan cheese. d) Temperature of food in South dining room At 8:36 a.m. on 12/14/17, dietary employee, #202 obtained the temperatures of the last tray served for breakfast. --Eggs 113 degrees --Oatmeal 132 degrees E #202 said the food should be above 140 degrees at the time of service. (The regulations require the food temperatures should be at 135 degrees at the time of service.) e) Appearance and Description of Food Confidential interviews at 12:32 p.m. on 12/11/17, with two residents in the south dining room found both felt the pepperoni calzone was over baked. One resident said she could not cut the calzone, the second said it was so hard she almost choked on it. A confidential interview at 8:19 a.m. on 12/12/17, found the resident complained about the appearance of the food served and how the menu did not always describe the food being served. The facility failed to ensure that food was served at the preferred temperatures and was palatable and appetizing in appearance. a) Palatable and appetizing b) North dining hall - temperature of food c) GB South dining hall - temperature of food Resident #88 Food F803 To assure that menus are developed and prepared to meet resident choices. F804 To assure that the nutritive value of food is not compromised 12/14/17 09:17 AM Interview during the Initial Pool Process Resident # 88 complained about food and his interview is to remain confidential, there are multiple complaints regarding food issues from several residents. f) North dining hall - temperature of food On 12/14/17 at 12:04 p.m., staff was observed starting to provide meals in the north dining room to the residents seated there. The last tray coming off the steam table in the North dining room was sent to a resident's room on 300 hall. The Dietary Manager and this surveyor followed the tray carts to 300 hall and at 1:20 p.m., the temperature of the food on the last tray was checked by the Dietary Manager. The soup was 111 degrees Fahrenheit (F), fish 130 degrees F and potatoes 129 degrees F. The Dietary Manager confirmed the temperatures were lower than they should be, hot foods are held at 135 F or higher on the steam table. g) Random opportunity for observation On 12/11/17, at 1:28 p.m., observation of a resident's tuna sandwich revealed the tuna sandwich was not spread across the bread. The tuna was in the center of the bread only. There was no tuna on the bread approximately one and one-half (1 1/2) inches around the edge of the bread. h) Confidential interviews with residents and families During a confidential interview with a resident's family member on 12/11/17 at 1:28 p.m., the family member made complaints about the facility's food. She stated she had to send back the food tray because the coleslaw and sandwich were on the same plate. She stated the coleslaw leaked onto the sandwich, making it soggy. She stated her family member was confused, and attempted to eat the soggy sandwich. She also reported sandwiches did not have enough filling. During a confidential interview on 12/14/17 at 6:30 p.m., two (2) residents reported the macaroni and cheese served for dinner did not have enough cheese. The two (2) residents stated they were not going to eat the macaroni and cheese.",2020-09-01
2864,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,810,D,0,1,EBN311,"Based on observation, record review, and staff interview, the facility failed to ensure Resident #46 received adaptive eating equipment as ordered by the physician. A weighted fork/spoon was not available for Resident #46. This was true for one (1) of eight (8) residents reviewed for the area of nutrition. Resident identifier: #46. Facility census: 123. Findings include: a) Resident #46 Review of the resident's medical record at 11:00 a.m. on 12/12/17, found the resident had an order to have a weighted fork/spoon at meals. The order was dated 11/15/17. Observation of the evening meal at 5:36 p.m. on 12/12/17, found the resident did not have weighted utensils for the evening meal. A second observation of breakfast at 7:55 a.m. on 12/14/17, found the resident again did not have weighted utensils. Licensed Practical Nurse (LPN) #23 and kitchen staff member, Employee #202 said they did not know the resident needed special utensils at 7:57 a.m. on 12/14/17. [NAME] #202 said all resident's special utensils are usually in the drawer but they are missing today.",2020-09-01
2865,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,814,C,0,1,EBN311,"Based on observation and staff interview the facility failed to ensure that garbage was disposed of properly in a manner that would prevent the attraction of vermin. Observation revealed a dumpster overflowing with bags of garbage as well as bags of garbage on the ground beside the dumpster. This practice had the potential to affect all residents. Facility Census: 123 Findings include: On 12/14/17 at 12:45 p.m., the Dietary Manager and this surveyor observed various debris laying on the ground beside three (3) trash dumpsters. Observed on the ground outside the trash dumpsters was a smashed used plastic milk jug without the lid, various small pieces papers, an empty cigarette, and pieces of food wrappers. The Dietary Manager confirmed no trash is to be laying on the ground but inside the trash dumpsters.",2020-09-01
2866,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,921,D,0,1,EBN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observations and staff interviews the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residentsl. Random observations on 300 hall revealed cluttered on both sides of the hallway making it difficult to maneuver safely through the hallway. Random observations of the laundry revealed areas that needed cleaned This practice had the potential to affect more than a limited number of residents. Facility Census: 123 Findings included: a) 300 Hall Clutter On 12/11/17 at 01:29 p.m., random observations of hall 300's hallway revealed items stored on both sides of the hallway. On the same side of the hall as room [ROOM NUMBER]; was a gerri chair recliner, a housekeeping cart, a cart with the ice cooler, a treatment cart which was not flushed against the wall but sat crookedly extended to the center of the hallway. A resident in a wheelchair was trying to get through the hall without assistance and had difficulty making any progress down the hall. On the opposite side of the hall was a medication cart, two (2) food tray carts and a beverage cart. Observations revealed staff and residents maneuvering with difficulty through the hallway. An interview with Nurse Aide (NA#90), on 12/11/17 at 01:35 p.m., confirmed the hall was cluttered and staff had been instructed to place equipment and items on one side of the hall to prevent clutter. b) On 12/14/17 at 9:30 a.m., a tour of the soiled laundry area with Accounts Manager #200 revealed the area behind the washing machines had a build up of dirt and debris. Two (2) ceiling vents had a build up of black dust and debris. On 12/14/17 at 9:45 a.m., Accounts Manager #200 agreed these areas needed cleaned.",2020-09-01
4253,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2016-11-16,282,D,0,1,3WOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure care plan interventions were implemented according to the residents ' comprehensive plan of care. This involved one (1) of three (3) residents investigated for accidents and pressure ulcers in Stage 2. Resident identifier: #30. Facility census: 126. Findings include: a) Resident #30 1. Cushion for wheelchair Resident #30 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] documented Resident #30 was cognitively impaired and exhibited no behaviors. This MDS also documented the resident required the extensive assistance of one staff member for bed mobility, transfers and is not able to balance herself without the assistance of staff. Review of the current skin care plan, on 11/15/16 at 9:20 a.m., revealed Resident #30 has current pressure ulcers and is at risk for the development of further skin breakdown as evidenced by the history of pressure ulcers. Current interventions include Resident #30 should have had a pressure relieving cushion in her wheelchair. During an observation of Resident #30, on 11/15/16 at 10:50 a.m. and 11:31 a.m., revealed she was seated in her wheelchair with no pressure cushion observed to be under her in the wheelchair. The Administrator #91 and Director of Nursing (DON) #43 were notified of the lack of the cushion in the resident's wheelchair and verified the resident should have a cushion in her wheelchair at all times. This surveyor and the DON #43 went to the residents ' room and the resident was transferred from her wheelchair to her bed. The DON #43 verified the resident did not have any type of cushion in her wheelchair and indicated she would obtain the proper pressure reliving cushion for the resident's wheelchair. Per further interview with the DON #43 on 11/15/16 at 2:10 p.m. she verified the lack of a pressure relieving device in the resident's wheelchair. She further stated they found the cushion in the resident's closet but it was not the proper cushion the resident should have in her wheelchair to reduce pressure. Interview with Nurse Aide #100, on 11/15/16 at 3:09 p.m. revealed Resident #30 used to have a cushion in her wheelchair but she was not sure where the cushion was anymore. Further interview with the DON, on 11/16/16 at 10:39 a.m., verified per Resident #30's current skin care plan she should have had a pressure reducing cushion in her chair at all times to promote wound healing. 2. Accidents Review of Resident #30's activity of daily living (ADL) care plan on 11/15/16 at 2:20 p.m. revealed she requires staff assistance and is dependent for ADL care in one or more of the following care areas: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to chronic disease/condition compromising functional ability. She was noted to be status [REDACTED]. A fall intervention required staff to provide Resident #30 with extensive assistance for bed mobility, transfers, dressing, eating, toileting, hygiene. Review of Resident #30's clinical record, on 11/15/16 at 9:33 a.m., revealed on 10/30/16 Resident #30 was found in her room on the floor beside her bed. The resident stated she was trying to get in bed, and missed the bed. She fell attempting to transfer from her chair to her bed unassisted and the brakes on her wheelchair were unlocked. No injuries were noted. There was no evidence staff were assisting her with transfers per of care plan. After this fall the staff implemented anti-roll back device to her wheelchair. Further record review revealed, on 11/12/16 at 5:50 p.m., Resident #30 was found lying on the floor in her room with no visible signs of injury. She was assisted back to bed and able to move all her extremities without pain. After this fall the fall care plan was updated with a new intervention to include staff were to assist her to ensure her feet are loose from the bedding during rounding. There was no evidence the staff were assisting the resident during her attempted transfer when this fall occurred. On 11/15/16 at 2:20 p.m., Resident #30 was observed to transfer herself from her wheelchair to her bed with no assistance. The Director of Nursing (DON) #43 and Nurse #132 were present during this observation of the resident performing a self-transfer. Observation again, on 11/15/16 at 4:05 p.m., revealed Resident #30 was observed to transfer herself from her wheelchair to her bed. She was observed to be unsteady as she transferred herself. During an interview with Nurse Aide (NA) #100, on 11/15/2016 at 3:18 p.m., she stated Resident #30 is able and does transfer herself from the bed to her wheelchair and from her wheelchair to her bed. When asked by this surveyor if she has to remind her to call for assistance she stated again Resident #30 is able to transfer herself without any assistance from staff and verified she does not assist her with transfers. During an interview with NA #26, on 11/16/16 at 3:00 p.m., she stated Resident #30 does not require any assistance with transfers or bed mobility. She stated she gets out of the bed all the time and places herself in her wheelchair with no problems. She stated she does not have to remind her to call for help because she is able to transfer herself and she does not provide her any assistance. Interview with Nurse #53, on 11/16/16 at 10:30 a.m., he stated Resident #30 is able to transfer herself from her bed to the wheelchair on her own with no staff assistance. He stated she may not always be safe when self-transfers but she does it anyway. Interview with Administrator #91 and DON #43, on 11/15/16 at 3:22 p.m., revealed Resident #30 should not be transferring herself. They verified based on her current fall care plan and interventions Resident #30 does require a one (1) person physical assistance for transfers due to an increase fall risk and she has experienced two (2) recent falls while attempting self-transfers.",2020-02-01
4254,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2016-11-16,314,D,0,1,3WOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure fall interventions for one (1) of three (3) residents investigated for accidents was implemented according to the residents ' plan of care. Resident identifier: #30. Facility census: 126. Findings include: a) Resident #30 Resident # 30 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] documented Resident #30 was cognitively impaired and exhibited no behaviors. This MDS also documented the resident required the extensive assistance of one staff member for bed mobility, transfers and is not able to balance herself without the assistance of staff. Review of the current skin care plan, on 11/15/16 at 9:20 a.m., revealed Resident #30 had pressure ulcers and was at risk for the development of further skin breakdown as evidenced by the history of pressure ulcers. Current interventions include Resident #30 should have a pressure relieving cushion in her wheelchair. The record revealed Resident #30 had a pressure ulcer upon admission to her coccyx which was noted to be unstageable with slough and noted as a suspected deep tissue injury. Review of the current wound documentation revealed upon admission the pressure ulcer on Resident #30's coccyx was noted to measure three (3) centimeters (cm) by two (2) cm and had decreased in size to now being one (1) cm by one (1) cm. The wound was coded as a deep tissue injury and was purple in color. During an observation, on 11/15/16 at 10:50 a.m. and 11:31 a.m. revealed Resident #30 seated in her wheelchair with no pressure cushion observed to be in the chair. The Administrator #91 and Director of Nursing Staff (DON) #43 verified the resident should have a cushion in her wheelchair at all times. The surveyor and the DON #43 went to the resident ' s room and the resident was transferred from her wheelchair to her bed. The DON #43 verified the resident did not have any type of cushion in her wheelchair and indicated she would obtain the proper pressure reliving cushion for the resident's wheelchair. Per further interview with the DON #43 on 11/15/16 at 2:10 p.m. she verified the lack of a pressure relieving device in the resident's wheelchair but stated they found a cushion in the resident's closet but it was not the proper cushion the resident should have in her wheelchair to reduce pressure. Interview with Nurse Aide #100, on 11/15/16 at 3:09 p.m., revealed Resident #30 used to have a cushion in her wheelchair but she was not sure where the cushion was anymore. Further interview with the DON, on 11/16/16 at 10:39 a.m. verified per Resident #30's current skin care plan she should have had a pressure reducing cushion in her chair at all times to promote wound healing. During an interview with the DON and Administrator, on 11/16/16 at 3:00 p.m., they both verified there should have been a cushion in her wheelchair to promote healing of her pressure ulcer on her coccyx.",2020-02-01
4255,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2016-11-16,323,D,0,1,3WOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide supervision and assistive devices to one (1) of three (3) residents reviewed in Stage 2 to prevent accidents. Resident identifier: #30. Facility census: 126. Findings include: Review of the medical record for Resident #30 revealed an admitted s of 09/06/16 with a [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), dated [DATE], documented Resident #30 was cognitively impaired and exhibited no behaviors. This MDS also documented the resident required the extensive assistance of one staff member for bed mobility, transfers and is not able to balance herself without the assistance of staff. Review of the most recent fall care plan, dated 09/07/16, revealed Resident #30 was at risk for falls and had impaired mobility and a goal indicated the resident will have no falls with injury throughout the next review period. Interventions included anti-rollbacks to the wheelchair, monitor for and assist the resident with toileting, staff are to assist the resident to ensure her feet are loose from bedding during rounding, one (1) person assist for all transfers and to place the call light within reach at all times. Review of Resident #30's activities of daily living (ADL) care plan, on 11/15/16, at 2:20 p.m. revealed she requires assistance and was dependent for ADL care in one (1) or more of the following care areas: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and related to chronic disease/condition compromising functional ability. She was noted to be status [REDACTED]. Another intervention was noted to provide Resident #30 with extensive assistance for bed mobility, transfers, dressing, eating, toileting, and hygiene. Review of Resident #30's clinical record, on 11/15/2016 at 9:33 a.m., revealed on 10/30/16 Resident #30 was found in her room on floor beside her bed. The resident stated she was trying to get in bed, and missed the bed. She fell attempting to transfer from her chair to bed unassisted. The brakes on her wheelchair were unlocked. No injuries were noted. After this fall the staff implemented anti-roll back device to her wheelchair. On 11/12/16 at 5:50 p.m., Resident #30 was found lying on floor in her room with no visible signs of injury. She was assisted back to bed and able to move all extremities without pain. After this fall the care plan was updated with a new intervention to include staff were to assist her to ensure her feet are loose from bedding during rounding. On 11/15/16 at 2:20 p.m., Resident #30 was observed to transfer herself from her wheelchair to her bed with no assistance. The Director of Nursing #43 and Nurse #132 were present during this observation. Observation again on 11/15/16 at 4:05 p.m., revealed Resident #30 was observed to transfer herself from her wheelchair to her bed. She was observed to be unsteady as she transferred herself, and she does not provide her any assistance. During an interview with Nurse Aide (NA) #100 on 11/15/16 at 3:18 p.m. she stated Resident #30 is able and does transfer herself from the bed to her wheelchair and from her wheelchair to her bed. When asked by this surveyor if she has to remind her to call for assistance she stated again Resident #30 is able to transfer herself without any assistance from staff, and she does not provide her any assistance. During an interview with NA #26, on 11/16/16 at 3:00 p.m., revealed Resident #30 does not require any assistance with transfers or bed mobility. She stated she gets out of the bed all the time and places herself in her wheelchair with no problems. She stated she does not have to remind her to call for help because she is able to transfer herself. Interview with Nurse #53, on 11/16/2016 at 10:30 a.m., revealed Resident #30 was able to transfer herself from her bed to the wheelchair on her own with no staff assistance. He stated she may not always be safe when self-transfers but she does it anyway. Interview with Administrator #91 and DON #43, on 11/15/16 at 3:22 p.m., revealed Resident #30 should not be transferring herself and stated she does require a one (1) person physical assistance due to an increase fall risk and she has had two (2) recent falls. Both of these noted falls occurred while the resident was performing a self-transfer which put Resident #30 at risk for further falls with potential for injury.",2020-02-01
4256,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2016-11-16,431,D,0,1,3WOC11,"Based on observations, staff interviews and review of the policy and procedure, the facility failed to dispose of expired medications and date medications after they were opened. This affected two (2) of six (6) medication carts on the south unit and the transitional care unit (TCU). Facility census: 126. Findings include: On 11/16/16 at 11:29 a.m., observations were made of two medication carts on the TCU. One (1) of the medication carts had a bottle of 130 tablets of Thera-Vitamins opened and dated on 10/16/16. The expiration date on the bottle of medication was 10/2015. Registered Nurse (RN) #6 was present during the observations and verified the medication was expired. Observations were also made on the same medication cart of one pint bottle of Lactulose 10 gm/15 ml bottle approximately half full. The bottle was opened and not dated. RN #6 was present during the observations and verified the medication had not been dated when the medication was opened. At 11:35 a.m. on 11/16/16, observations were made of two medication carts on the South unit. One of the medication carts were observed to have two, one pint bottles of Lactulose 10 gm/15 ml approximately half full opened and not dated. Observations were also made of one 16 ounce bottle of Milk of Magnesia approximately half full, opened and not dated. Licensed Practical Nurse (LPN) #53 was present during the observations and verified the medications were not dated when they were opened. At 11:37 a.m. on 11/16/16, the Director of Nursing (DON) #43 was interviewed and stated there was a system in place to check for expired medications, and to ensure medications are opened and dated. The DON stated the Unit Managers were supposed to check every Friday to ensure medications are stored properly. At 11/16/16 on 11:49 a.m., the Storage and Expiration Dating of Drugs, Biologicals, Syringes, and Needles policy was reviewed. The policy stated drugs are to be stored under proper conditions with regards to expiration date as directed by state and federal regulations and manufacturer/supplier guidelines. The process indicated the consultant pharmacist, nurse or other appropriate pharmacy personnel inspects nursing station storage areas for proper storage compliance on a regular scheduled basis",2020-02-01
5022,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2016-04-14,241,D,1,0,110411,"> Based on a random observation and staff interview, the facility failed to promote care in a manner and in an environment that enhanced Resident #58's dignity. Nurse Aide #68 was overheard speaking to Resident #58 in an undignified manner. This was discovered through a random opportunity for discovery and only affected an isolated number of residents. Resident identifier: #58. Facility Census: 121. Findings include: a) Resident #58 While walking down the 200 hallway at 10:20 a.m. on 04/14/16, Nurse Aide (NA) #68 was overheard saying, I will have to ask your nurse. I don't give medications. I am just a butt wiper. NA #68 said this statement in a loud tone from the hallway and directed it to a resident who was sitting in her room by the window. An interview with NA #68 at 10:25 a.m. on 04/14/16, confirmed she made this statement to Resident #58. She stated the resident asked her about her medications, and this prompted her to make this statement. When asked if this was a respectful statement to make NA #68 stated, I don't think that it was very nice to say that. She agreed that she should not have made the statement to the resident. She agreed she should have just informed the resident that she was not a nurse and did not give medications and not referred to herself as a butt wiper to the resident. An interview with the Nursing Home Administrator (NHA) at 10:28 a.m. on 04/14/16, confirmed NA #68 should not have said that to any resident. She stated, I can't believe that any of my staff would say something like that. I will take care of it immediately.",2019-04-01
5023,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2016-04-14,250,D,1,0,110411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, resident interview, and medical record review, the facility failed to provide medically-related social services to assist one (1) of six (6) sample residents to ensure she received restorative services. Resident #36 missed several sessions of restorative care due to being out of the facility with her family. The facility had not explored an alternative restorative care schedule with the resident that would better fit her needs. Resident identifier: #36. Facility census: 121. Finding include: a) Resident #36 On 04/13/16 at 3:00 p.m., during an interview with Resident #36, she stated she was getting restorative nursing care for ambulation, but she did not get ambulated everyday. Review of the medical record for Resident #36 on 04/13/16 at 3:35 p.m., found she had an order written [REDACTED]. Further record review revealed restorative nursing records for (MONTH) (YEAR) and (MONTH) (YEAR) with the following noted: -- On 03/27/16 Resident #36 did not receive ambulation by restorative nursing with not applicable (NA) marked. -- On 03/31/16 Resident #36 did not receive ambulation by restorative nursing with not applicable (NA) marked. -- On 04/01/16 Resident #36 did not receive ambulation by restorative nursing with not applicable (NA) marked. -- On 04/02/16 Resident #36 did not receive ambulation by restorative nursing zero (0) listed as the number of minutes received. -- On 04/03/16 Resident #36 did not receive ambulation by restorative nursing with out of the facility (OOF) marked. -- On 04/07/16 Resident #36 did not receive ambulation by restorative nursing with not applicable (NA) marked. -- 04/08/16 Resident #36 did not receive ambulation by restorative nursing with not applicable (NA) marked. -- 04/09/16 Resident #36 did not receive ambulation by restorative nursing with not applicable (NA) marked. -- Resident #36 did not receive ambulation by restorative nursing with not applicable (NA) marked. Review of the sign out book (book used to log when residents go out of, and return to, the facility) revealed Resident #36 was out of the facility on several occasion in the afternoon during (MONTH) and (MONTH) (YEAR). On 04/14/16 at 11:00 a.m., during an interview with the Director of Nursing (DON), she stated Resident #36 went out with her family almost everyday. The DON explained the resident possibly missed restorative session because she was out with her family. The DON stated the facility did not explore the possibly of rescheduling restorative sessions due to the resident going out of the facility with her family. The DON confirmed that the facility should explore the possibly of changing the restorative schedule due to the resident going out of the facility.",2019-04-01
5024,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2016-04-14,310,G,1,0,110411,"**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 #3's ability to ambulate did not decline unless unavoidable. This was true for one (1) of six (6) sampled residents. Resident #3's physical therapy was discontinued on 01/25/16 at which time he was able to ambulate 55 feet with minimal assistance using a wheeled walker with contact guard and verbal cues. His prognosis at the time of discharge from physical therapy was, Good to maintain min (minimal) a (assist) overall with RNP (Restorative Nursing Program) and nursing transfers. The physical therapist recommended a Restorative Nursing Program for gait training/ambulation. This restorative nursing program was never implemented and Resident #3 was not assisted with ambulation by nursing after his discharge from physical therapy on 01/25/16. On 03/16/16 physical therapy completed another evaluation and Resident #3 was placed back onto therapy's caseload. The residents' baseline ability to ambulate with a wheeled walker on 03/16/16 was 10 feet with maximal assistance. This demonstrated a significant decline in the distance he was able to ambulate and his assistance needed when ambulating compared to his abilities at discharge from physical therapy on 01/25/16. The facility's failure to provide the recommended RNP to Resident #3 upon his discharge from physical therapy on 01/25/16 likely contributed to Resident #3's decline in his abilities to ambulate therefore constituting actual harm to Resident #3. Resident Identifier: #3. Facility Census: 121. Finding include: a) Resident #3 Review of Resident #3's medical record at 12:46 p.m. on 04/12/16, found an admission date of [DATE]. Further review of the medical record found he received physical therapy during the following time frames: 09/21/15 through 10/19/15, 01/11/16 through 01/25/16, and 03/16/16 through 03/25/16. Review of the physical therapy initial evaluation dated 01/11/16 completed by the Director of Rehabilitation Physical Therapist (PT) # 150 found, Resident #3 placed onto Physical Therapy's case load on 01/11/16 with a long term goal of being able to safely ambulate on all surfaces 20 feet using a wheeled walker and contact guard with verbal cues to achieve reduction in risk of falls and/or functional decline. Review of the physical therapy discharge summary completed by PT #150 on 01/29/16 found upon discharge from physical therapy on 01/25/16, Resident #3 was able to ambulate 55 feet with minimal assistance. In the comments section PT #150 noted, again min (minimal) a (assistance) consistently but improved from overall mod (moderate) a (assistance) and buckling during gt (gait) gt (gait) pattern has improved. The discharge recommendations of PT #150 was for Resident #3 to have a RNP for gait training/ambulation and minimal assistance transfers with nursing. The discharge [DIAGNOSES REDACTED]. Further review of the medical record found no indication the RNP recommended by PT #150 for Resident #3 was ever implemented. Review of the restorative nursing records found no records for this time frame. Review of the Activities of Daily Living (ADL) flow sheets found Resident #3 had no occurrences of ambulation in his room or in the corridor until (MONTH) (YEAR). Review of the Physical Therapy Initial Evaluation completed by PT #150 on 03/16/16 (electronically signed for completion on 03/20/16) found the following under the section titled, Problem List/Impairments typed as written: Pt (Patient) at this time does show a decline in overall gt (gait) with RW (rolling walker) and max ( maximal) a (assistance) levels with significant knee instability and increase risk for falls. pt is min (minimal) a (assistance) overall with transfer from bed to chair and to bed but unsafe and buckling of B (Bilateral) knees in stance also showing increase risk for falls. weakness noted In BLE (bilateral lower extremities) with RNP completed. Under the section titled, Skilled Justification, PT #150 noted (typed as written): pt (patient) at this time requires P[NAME] (Plan of Care) x (times) 1 wk (week) to regain strength and min (minimal) a (assistance) overall with with gt (gait/ambulation) and RNP to maintain function and activity within facility at max (maximum) potential. pt (patient) request due to his noted decline and request to walk daily. PT #150 noted a decline in the residents gait/ambulation with a rolling walker. She also noted the RNP was completed however there is no indication in the record that Resident #3 ever received a RNP after his most recent discharge from Physical Therapy on 01/25/16. Due to Resident #3's noted declines he was again placed on the Physical Therapy case load and the following long term goals were developed, Patient will safely ambulated on all surfaces 50 feet using a Wheeled Walker with minimal assistance with verbal cues to achieve a reduction in risk of falls and/or functional decline. And, Complete as RNP for gt (gait training) as well as there (therapeutic) ex (exercises) for 3-5 times per week for 6 weeks to maintain min (minimal) a (assistance) activity for gt (gait/ambulation) within facility per pts (patients) request. PT #150 noted Resident #3's baseline on 03/16/16 in regards to ambulation was 10 feet with maximal assistance. This was a significant decline from his noted status by PT #150 on 01/25/16 of 55 feet with minimal assistance. An interview with PT #150 at 3:53 p.m. on 04/12/16, confirmed Resident #3's RNP was not implemented upon his discharge from physical therapy on 01/25/16. She indicated she should have completed a Restorative/Rehabilitation Nursing Program Plan and then met with the Restorative Nurse and educated Restorative on the plan. She indicated this was never done therefore nursing was not aware Resident #3 needed to be placed on a restorative ambulation plan. PT #150 was then asked what type of RNP did Resident #3 require in (MONTH) (YEAR) she stated the plan should have been implemented for ambulation with a rolling walker to maintain and/or improve his ambulation abilities at the time of his discharge from Physical Therapy on 01/25/16. PT #150 was then asked why Resident #3 required physical therapy again beginning on 03/16/16, she indicated that it was due to a decline in his ability to ambulate and that he and his family indicated he would like to have assistance with walking each day to build up his strength. PT #150 was then asked if Resident #3 has since regained and maintained his abilities to ambulate since his Physical therapy and the subsequent RNP began in (MONTH) (YEAR) she stated that he has. An interview with Resident #3 at 8:30 a.m. on 04/14/16 confirmed that he was now getting to walk almost every day with nursing. He stated he can tell his legs are getting a lot stronger and that he has made big improvements since (MONTH) (YEAR). He indicated that he wishes they would have been helping him to walk sooner than this. During an interview with the Director of Nursing (DON) at 10:06 a.m. on 04/13/16, she asserted Resident #3 could not have had a decline in ambulation since prior to his most recent discharge from therapy on 03/23/16 he had never walked with nursing. Her statement is true, nursing had not assisted Resident #3 with walking until 03/29/16 which is the date his current RNP began. This however; was not because Resident #3 was unable to walk, but was a result of the facility's failure to implement the RNP for ambulation recommended by PT #150 upon his discharge from physical therapy on 01/25/16. At that time he had the ability to walk at least 55 feet with minimal assistance as noted in the Physical Therapy Discharge Summary. If the facility would have implemented the RNP then Resident #3 would have began walking with nursing prior to 03/29/16 and could have possibly avoided the decline in his ambulation ability between 01/25/16 and 03/16/16.",2019-04-01
5025,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2016-04-14,441,E,1,0,110411,"> Based on observation and staff interview, the facility failed to ensure safe storage of clean linen. Observations of a linen cart with clean linen was uncovered on multiple occasions during the survey. This practice created the potential for transition of disease and infection for more than a number of isolation resident. Facility census: 121. Finding include: a) Clean linen cart On 04/11/16 at 1:40 p.m., observed the clean linen cart located on the North hallway between rooms 111-113. The clean linen cart was uncovered. On 04/11/16 at 2:00 p.m., the clean linen cart remained uncovered. On 04/12/16 at 9:25 a.m., observed the clean linen cart located on the North hallway between rooms 111-113. The clean linen cart was uncovered. On 04/12/16 at 2:30 p.m., the clean linen cart remained uncovered. On 04/13/16 at 8:20 a.m., observed the clean linen cart located on the North hallway between rooms 111-113. The clean linen was uncovered. This issue was brought to the attention of Unit Manager (UM) #26, she agreed that the clean linen cart should be covered. At this time she pulled the cover down over the clean linen cart.",2019-04-01
5026,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2016-04-14,514,E,1,0,110411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure three (3) of six (6) medical records reviewed were complete and accurate. Resident #3 and Resident #19's medical record had incomplete documentation related to the administration of an as needed pain medication. Additionally, Resident #19's physical therapy notes did not accurately reflect his status as it related to his refusal for a restorative nursing program. Resident #26's medical record did not contain documentation related to active discharge planning and the effects of her stroke on her psychosocial well being. The social service department was involved with the resident in both areas, but the medical record did not reflect the social workers involvement with the resident. Resident Identifiers: #3, #19, and #26. Facility Census: 121. Findings include: a) Resident #3 A review of Resident #3's medical record at 9:14 a.m. on 04/13/16 found a physician's orders [REDACTED]. This order had a start date of 12/03/15. A review of Resident #3's medication administration record (MAR), the PRN Pain Management Flow Sheet, and the controlled substance log for this medication found the following incomplete documentation in Resident #3's medical record. On the following dates and times the medication was signed out on the controlled substance log but was not documented as administered on the MAR or the PRN Pain Management flow sheet: -- 03/24/16 at 3:00 p.m. -- 03/28/16 at 10:30 a.m. -- 03/28/16 at 4:30 p.m. -- 04/07/16 at 4:00 a.m. On the following dates and times the medication was signed out on the controlled substance log and initialed as administered on the MAR but was not documented on the PRN Pain management Flow Sheet: -- 03/24/16 at 9:00 a.m. -- 03/31/16 at 9:00 p.m. -- 04/02/16 at 6:00 p.m. On the following dates and time the medication was signed out on the controlled substance log and documented on the PRN (as needed) Pain Management flow sheet but was not recorded on the MAR: -- 03/11/16 at 5:00 p.m. -- 03/12/16 at 7:00 p.m. -- 03/17/16 at 2:00 a.m. -- 04/12/16 at 9:00 p.m. An interview with the Director of Nursing (DON) at 12:13 p.m. on 04/13/16, confirmed when a PRN pain medication is administered it should be documented in three separate locations. She indicated they should sign it out on the controlled substance log, initial the MAR to indicate the medication was administered, and fill out the the PRN pain management flow sheet. The incomplete documentation was reviewed with her and she agreed there was missing documentation in the residents medical record making it an incomplete medical record. b) Resident #19 1. Documentation related to PRN Pain Medication. A review of Resident #19's medical record at 1:20 p.m. on 04/13/16 found a physician's orders [REDACTED]. This order had a start date of 06/26/15. A review of Resident #19's medication administration record (MAR), the PRN Pain Management Flow Sheet, and the controlled substance log for this medication found the following incomplete documentation in Resident #19's medical record for the time frame of 03/01/16 through 03/17/16 and 03/25/16 through 04/13/16. (Resident was on a therapeutic leave of absence from 03/17/16 through 03/24/16.) On the following dates and times the medication was signed out on the controlled substance log but was not documented as administered on the MAR or the PRN Pain Management flow sheet: -- 03/12/16 at 2:00 p.m. -- 04/09/16 at 6:00 a.m. -- 04/13/16 at 3:00 a.m. On the following dates and times the medication was signed out on the controlled substance log and initialed as administered on the MAR but was not documented on the PRN Pain management Flow Sheet: -- 03/10/16 at 9:00 p.m. -- 03/11/16 at 9:00 p.m. -- 03/14/16 at 12:00 p.m. and 8:00 p.m. -- 03/15/16 at 8:00 a.m. -- 03/16/16 at 8:00 p.m. -- 03/17/16 at 9:00 p.m. -- 03/26/16 at 10:00 p.m. -- 03/27/16 at 12:00 p.m. and 6:00 p.m. -- 03/28/16 at 12:00 a.m., 6:00 a.m. and 6:00 p.m. -- 03/29/16 at 9:00 p.m. -- 03/30/16 at 12:00 p.m. and 8:00 p.m. -- 03/31/16 at 4:00 a.m., and 8:00 p.m. -- 04/01/16 at 4:00 a.m. -- 04/03/16 at 12:00 p.m. -- 04/05/16 at 9:00 p.m. -- 04/08/16 at 4:00 a.m., and 10:00 p.m. -- 04/09/16 at 5:00 p.m. and 9:00 p.m. -- 04/10/16 at 11:00 a.m. -- 04/11/16 at 8:00 p.m. An interview with the DON at 3:05 p.m. on 04/13/16, confirmed when a PRN pain medication is administered it should be documented in three separate locations. She indicated they should sign it out on the controlled substance log, initial MAR to indicate the medication was administered, and fill out the the PRN pain management flow sheet. The incomplete documentation was reviewed with her and she agreed there was missing documentation in the residents medical record making it an incomplete medical record. 2. Inaccurate Physical Therapy Discharge Summary Review of Resident #19's medical record at 3:51 p.m. on 04/13/16, found a physical therapy discharge summary dated 04/07/16. This summary was completed by Physical Therapist (PT) #150. The summary indicated Resident #19 was discharged from physical therapy on 04/04/16 with recommendations for a Restorative Nursing Program to help him maintain his functional status. An interview with PT #150 at 10:00 a.m. on 04/14/16, confirmed she never referred Resident #19 to restorative therapy. She stated that when she was discharging Resident #19 from physical therapy she asked him if he would participate with a restorative program. She indicated the resident declined and stated he just wanted to go home and did not want to participate with restorative. She stated that she should have deleted it from the discharge summary prior to finalizing it but she forgot to do so. She agreed the discharge summary did not accurately reflect Resident #19's status. c) Resident #36 During an interview with Resident #36 on 04/13/16 at 3:00 p.m., Resident #36 expressed she had suffered a stroke ([MEDICAL CONDITION]). The resident was tearful. She was concerned about being able to walk again. She was also upset because of an over due bill that she owed the facility. She said the facility told her that they would have to issue her a 30 day notice. Resident #36 expressed concern where she would live if she had to leave the facility. Resident #36 stated that she needed 24 hour care and no friend or family member could provide that for her. Medical record review on 04/13/16 at 3:45 p.m., did not reveal any documentation regarding the issues expressed by the resident. During interview with Social Worker #19 on 04/14/16 at 10:30 a.m., the social worker stated that she was not her social worker but she did know some information about Resident #36. Social worker #19 stated that social worker #37 was assigned to Resident #36 but she was not available today. Social Worker #19 stated that she had talked to Resident #36 on 04/08/16 about moving into an apartment and applications that had been made for her. Social Worker #19 said Resident #36 expressed sadness over not being able to return home to live with her girlfriend. Social Worker #19 agreed that she had not document her conversations with Resident #36 in the medical record. An interview with the administrator on 04/14/16 at 10:45 a.m., revealed that she had discussed with Resident #36 her over due bill. She confirmed that she discussed with Resident #36 the status of her over due bill. She had told Resident #36 the facility may issue a 30 day discharge notice because of the over due bill. The administrator confirmed she did not document any of the conversations with Resident #36 in the medical record.",2019-04-01
5262,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2016-02-11,315,E,1,0,BHHJ11,"> Based on observation and staff interview, the facility failed to ensure residents who were incontinent of bladder received the appropriate services to prevent urinary tract infections. This practice affected three (3) residents who were observed receiving incontinence care, but had the potential to affect more than a limited number of residents. Resident identifiers: #81, #4, and #44. Facility census: 127. Findings include: a) Resident #81 During an observation of incontinence care, on 02/10/16 at 4:56 p.m., Nurse Aide (NA) #118 was in the room preparing to perform incontinence care. Upon inquiry, Resident #81 gave permission to observe the procedure. Resident #81 was seated on the side of the bed, feet on the floor, facing the center of the room. The NA, who had already donned gloves, walked into the bathroom, and retrieved a handful of wet washcloths from the sink basin. She pulled a roll of bags from her smock, placed a bag on the bed, and placed a clean brief on the bed. NA#118 asked Resident #81 to lie down. The NA reached across the bed and pulled on Resident #81's pant leg to assist him to get his legs and feet on the bed. After assisting the resident to remove his pants, the NA cleansed the resident's peri area with a wet cloth. She did not pull back the foreskin and cleanse the meatus (opening where urine leaves the body). The nurse aide applied a clean brief and clothing. NA #118 removed her gloves, washed her hands for a count of five (5) seconds and turned off the faucet with her bare hands. The NA did not wash her hands for 15 to 20 seconds and recontaminated her hands when she turned the faucet off with her bare hands. b) Resident #4 On 02/11/16, Nurse Aide (NA) #125 donned gloves, obtained a washbasin, turned on the bathroom faucet with her gloved hand, and filled the basin with water. The NA turned the water on and off with her gloved hand, thus contaminating her glove. The NA returned to the bedside and placed the basin on the nightstand, then removed the resident's soiled brief, which contained brownish colored urine. The NA washed Resident #4's legs, then buttocks, legs again, and buttocks again with the same washcloth. c) Resident #44 On 02/11/16 at 3:15 p.m., Nurse Aide (NA) #40 entered the room of Resident #44 to perform incontinence care. The NA donned gloves, obtained a washbasin and turned on the water faucet with her gloved hand. The NA filled the basin and turned the faucet off with the same gloved hand. The NA returned to the bedside and placed the basin on the over-the-bed table. The NA raised the bed, turned on the light, and pulled the covers down, exposing the resident. NA #40 unfastened the resident's soiled brief and exposed the resident's peri area. Using body wash, the NA wiped Resident #44's groin area, then his penis. NA #40 did not pull back the foreskin and wash the urinary meatus. After NA #40 cleansed Resident #44, she applied a new brief without first drying the resident, or thoroughly cleansing him. Upon inquiry as to the substance in the resident's pubic hair at the base of his penis, the NA replied, I didn't see it. NA #40 removed her gloves, washed her hands and exited the room. She returned with washcloths. The NA wet the cloth and without applying cleanser, washed the peri area, allowing water to run down the resident's thigh area. Without drying Resident #44's peri-area and thighs, the NA applied a clean brief. d) The director of nursing (DON), interviewed on 02/11/16 at 9:40 a.m., related the facility practice for linen handling required staff to change gloves when transitioning from a dirty task to a clean task, and related hand hygiene should be performed. The DON related she had taught staff to sing the Happy Birthday song for a count of fifteen (15) to thirty (30) seconds, rinse hands and turn off the faucet with a paper towel. Additionally, the DON confirmed incontinence care was performed incorrectly. The foreskin should have been retracted and cleansed. Insufficient or improper handwashing created a potential for cross contamination, and improper care, such as not drying the resident's skin provided an opportunity for skin breakdown and yeast/fungal type infections.",2019-02-01
5263,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2016-02-11,441,F,1,0,BHHJ11,"> Based on observation, staff interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and policy review, the facility failed to maintain an effective infection control program to prevent the transmission of disease and infection to the extent possible. Staff utilized improper hand hygiene practices and handled linens improperly. This practice affected five (5) residents, located in different areas of the facility, and had the potential to affect all residents. Resident identifiers: # 117, #81, #4, #3, and #122. Facility census: 127. Findings include: a) Resident #117 During an observation on the initial tour of the facility, on 02/09/16 at 8:45 a.m., Nurse Aide (NA) #74 provided care to Resident #117. Observation revealed a soiled brief on the floor beside the bed. The NA had donned gloves and was positioning the resident onto a lift pad. Upon completion of the task, the NA reached into his pocket with the contaminated glove and removed a roll of clear plastic garbage bags. He obtained one, reached down and picked up the soiled brief off the floor. The NA entered the bathroom and closed the door, exited the bathroom still wearing the gloves, picked up the bag containing the brief and exited the room. b) Resident #4 A random observation, on 02/10/16 at 9:03 a.m., revealed Nurse Aide (NA) #92 exiting the room of Resident #4. The NA carried a garbage bag and uncontained linens. He stopped at the doorway, looked down the hallway, went back into the room, turned around and exited the room. The NA proceeded down the hallway and disposed of the linens in the soiled linen cart. c) Resident #3 On 02/11/16 at 9:15 a.m., a random observation noted a pile of soiled linens on the floor at the foot of the resident's bed and a sheet on the floor by the side of the bed facing the door. The resident was seated on the side of the bed, facing the center of the room. Nurse Aide (NA) #130 was assisting the resident and related she was finishing morning care. The NA, who was wearing gloves, continued with the resident's care, transferred the resident to his wheelchair, and assisted him to the hallway. She then returned and picked up the soiled linen, placed it in a plastic bag, and disposed of it in the soiled hamper located in the hallway outside the door of the room. NA#130 removed her soiled gloves, applied new gloves, and without performing hand hygiene, obtained clean linens from the linen closet in the hallway. d) Resident #122 An observation on 02/11/16 at 9:29 a.m., revealed Nurse Aide (NA)#49 exiting the room of Resident #122. She had a pile of soiled linens in her arms and against her uniform, and was placing them in a soiled linen cart outside the doorway. The NA carried them in a hugging manner and she was not wearing gloves. The NA entered the room and without performing hand hygiene, donned a pair of gloves. She removed a mattress overlay from the resident's closet, and indicated she was packing items in preparation for the resident's discharge. e) Resident #81 During an observation of incontinence care, on 02/10/16 at 4:46 p.m., Nurse Aide (NA) #118 performed incontinence care for Resident #81. Upon completion of the procedure, without removing her soiled gloves, the NA touched the clean roll of garbage bags she kept in her pocket, and moved the over-the-bed table. Nurse Aide #118 then washed her hands for a count of five (5) seconds and turned off the faucet with her bare hands. She then placed the call bell near the resident and exited the room without washing her hands. f) The director of nursing (DON), interviewed on 02/11/16 at 9:40 a.m., said the facility's practice for linen handling required staff to place linens in a plastic bag before disposing of them. The nurse related staff should not hold the linens against the body and acknowledged a potential for cross contamination. The DON also stated gloves should be changed when transitioning from a dirty task to a clean task, and hand hygiene should be performed. The DON commented she had taught staff to sing the Happy Birthday song for a count of fifteen (15) to thirty (30) seconds, rinse hands and turn off the faucet with a paper towel. g) The linen handling policy, reviewed on 02/11/16 at 9:53 a.m., revealed staff should cleanse their hands before handling clean linen. All soiled linen was handled the same and included standard precautions, wear gloves, remove gloves and wash hands after handling soiled linen and before transporting clean linen. It noted all linen must be bagged. h) The facility's hand hygiene policy, reviewed on 02/11/16 at 9:58 a.m., confirmed hand hygiene should be performed before and after direct patient care, immediately after contact with blood, body fluids, or other potentially infectious materials . when moving form a contaminated body part to a clean body site during patient care, after contact with inanimate objects in the immediate vicinity of the resident, before and after assisting with meals, and after removing gloves. i) Additionally, according to the Centers for Disease Control and Prevention guidelines, proper technique for handwashing requires staff to wash their hands with warm water, apply soap to hands, and rub vigorously for at least fifteen (15) to twenty (20) seconds covering all surfaces of the hands and fingers, rinse with warm water, dry thoroughly with a disposable towel, and use paper towel to turn off the faucet.",2019-02-01
5425,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2015-09-17,242,E,0,1,C8VX11,"Based on resident interview and staff interview, the facility failed to ensure residents were afforded their right to exercise autonomy regarding what they felt was an important aspect of their lives. Residents #3 and #86 were not afforded the opportunity to receive their preference of more than two (2) showers each week. This was true for two (2) of three (3) resident's reviewed for the care area of Choices during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #3 and #86. Facility census: 123. Findings include: a) Resident #3 At 4:18 p.m. on 09/14/15, during Stage 1 of the QIS, Resident #3 stated she could not receive more than two (2) showers a week. She stated she was told the facility only gave two (2) showers a week because, More showers would cause older peoples' skin to dry out. She stated she was not old and if she were at home, she would take a daily shower. The resident said she was only fifty-three (53) years old and she would prefer a daily shower. On 09/15/15 at 1:20 p.m., review of the resident's shower schedules for the months of (MONTH) (YEAR) and (MONTH) (YEAR), found the resident only received two (2) showers each week. Review of the resident's medical record, at 2:00 p.m. on 09/15/15, found the resident scored a 15 on her brief interview for mental status (BIMS) on the most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 09/05/15. A score of 15 indicated the resident was cognitively intact in Section C entitled Cognitive Patterns C0500. b) Resident #86 At 2:21 p.m. on 09/14/15, the resident stated she did not get to choose how many times a week she got a shower. She stated she only got two (2) showers a week, which was determined by the facility. She said she would prefer to shower daily. On 09/15/15 at 1:30 p.m., review of the resident's shower schedule for the months of (MONTH) (YEAR) and (MONTH) (YEAR), found she received only two (2) showers a week. Review of the resident's most recent MDS, a significant change MDS, with an ARD of 06/19/15, found the resident received a score of 13 on her BIMS in Section C, entitled cognitive patterns. A score of 13 indicated the resident was cognitively intact. c) On 09/15/15 at 2:36 p.m., Registered Nurse (RN) #68, an RN working on the unit on which both residents resided, was asked how the facility determined a resident's shower schedule. She stated, I am assuming that we decide based on our schedule. If they ask for an extra one we try to get them in on that day. It depends on what room they are in as to the shower schedule. It's a pre-determined schedule based on their room. d) At 2:50 p.m. on 09/15/15, the director of nursing (DON) was asked how the facility determined the resident's shower schedule. She stated the activities department interviewed the residents and noted their preferences in the care plan. Review of both resident's current care plans with the DON, found the activities director noted both resident's preferred showers, but the care plan did not include any information regarding the number of showers each resident preferred. At 2:57 p.m. on 09/15/15, the DON confirmed she was unable to find any evidence the facility had asked or offered more showers to Residents #3 and #86, other than the facility's practice of providing two (2) showers per week.",2019-01-01
5426,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2015-09-17,247,D,0,1,C8VX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, record review, staff interview, and policy review, the facility failed to notify the resident and/or responsible party of one (1) of two (2) residents reviewed for room changes of an upcoming room change. Resident identifier: #244. Facility census: 123. Findings includes: a) Resident #244 On 09/14/15 at 5:35 p.m., during a Stage I interview for the Quality Indicator Survey, Resident #244's responsible party was asked, Were you given notice before a room change or a change in roommate? The resident's responsible party stated, No, (Resident #244's name) moved from the transitional care unit to the room she is in now. A review of Resident #244's medical records, on 09/17/15 at 1:56 p.m., revealed Resident #244 moved from room [ROOM NUMBER]-b to room [ROOM NUMBER]-b. There was no evidence the resident/responsible party was notified of the room change. In an interview with the Administrator on 09/17/15 at 2:00 p.m., when asked whether Resident #244's responsible party was notified of the room change the Administrator stated, No. On 09/17/15 at 2:19 p.m., a review of the facility's policy for room change, found in included the staff would notify the patient and/or responsible party of the room transfer. All room changes will be documented in a progress note or on the room transfer/new roommate change form.",2019-01-01
5427,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2015-09-17,253,D,0,1,C8VX11,"Based on observation and staff interview, the facility failed to ensure it provided housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Six (6) of thirty-six (36) rooms had furniture and/or other areas within the room in need of repair. Issues identified included scuffed and marred furniture, privacy curtains that were not secured as they should have been, cracked ceiling tile and chipped paint. This had the potential to affect more than an isolated number of residents. Room numbers: #116, #118, #119, #124, #319, and #320. Facility census: 123. Findings include: a) Room 116 On 09/14/15 at 5:47 p.m., observations found both sides and the front of the chest of drawers across from Bed A were badly scuffed with multiple marred areas. b) Room 118 Observations on 09/15/15 at 9:16 a.m., revealed the bedroom and bathroom floors had various pieces of debris scattered across the floors. The bathroom ceiling had an area that was cracked and split open. Just above the bathroom mirror lights were three (3) areas that appeared scorched and were covered with clumps of dust. These three (3) areas were directly above each of the three (3) light bulbs. Maintenance Helper #88 was notified concerning the areas that appeared scorched. He stated they had had an issue where 60-watt light bulbs had been placed where 40-watt light bulbs should have been, but that all the light bulbs had already been replaced with 40-watt bulbs. The Maintenance Director was notified and the temperature of the area above the three (3) light bulbs was tested and found the 40 watt light bulbs, now in the fixture, were not putting off excessive heat. The discolored dusty area was wiped cleaned. The Maintenance Director started immediately repairing the crack in the bathroom ceiling. c) Room 119 Observations on 09/14/15 at 4:47 p.m., found sections of veneer missing from the over-bed tray edge and the bedside nightstand, leaving jagged edges and exposed unfinished wood. d) Room 124 On 09/14/15 at 02:55 p.m., observations of Room #124 revealed the bedside nightstand beside Bed B, had a section of veneer pulled off, leaving jagged edges and exposed unfinished wood. e) Room 319 On 09/14/15 at 04:18 p.m., observations revealed the lower portion of the corner wall adjacent to the bathroom had paint chipped off and pieces of plaster missing. The privacy curtain between beds A and B was not hanging properly or evenly due to the curtain not being attached to the hooks in some places. f) Room 320 Observations on 09/14/15 at 04:06 p.m., revealed the lower portion of the corner wall adjacent to the bathroom had chipped and scratched paint. g) On 09/12/15 at 2:45 p.m., during another tour of Rooms #116, #118, #119, #124, #319, and #320 with the maintenance director, he agreed with the findings concerning the over-bed tray, bedside nightstands, bathroom ceiling, privacy curtain, and walls in the rooms toured were in disrepair. The maintenance director said these issues would be addressed.",2019-01-01
5428,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2015-09-17,272,E,0,1,C8VX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to conduct accurate comprehensive Minimum Data Set (MDS) assessments for three (3) of three (3) residents reviewed for the care area of accidents and for one (1) resident reviewed for the care area of urinary catheter. The MDS assessments for Residents #79, #152 and #217 were inaccurate in the area of mood and behavior patterns. The assessment for Resident #17 was inaccurate in the area of disease [DIAGNOSES REDACTED].#79, #152, #217, and #17. Facility census: 123. Findings include: a) Resident #79 A review of Resident #79's medical records, on 09/15/15 at 1:30 p.m., revealed an admission date of [DATE]. The medical records contained an Admission MDS with an assessment reference date (ARD) of 07/14/15. This MDS, in item E1000A Wandering - Impact, indicated Resident #79's wandering placed the resident at significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility). During an interview, on 09/16/15 at 11:15 a.m., the Director of Nursing (DON), Social Service Director (SSD) and the Clinical Reimbursement Coordinator CRC, all confirmed the MDS with an ARD of 07/14/15 was inaccurate. The MDS was immediately corrected by the CRC. b) Resident #152 A review of Resident #152's comprehensive MDS, with an ARD of 08/26/15, on 09/15/15 at 3:00 p.m., revealed under item E behavior-1000- wandering-impact. Question E1000-A asked, Does the wandering place the resident at significant risk of getting to a potentially dangerous place, e.g., stairs, outside of the facility. The answer to this question was, Yes. A review of Resident #152's behavior monitoring sheet for this look back period, on 09/15/15 at 4:00 p.m., revealed no evidence Resident #152's wandering posed a significant risk of getting in a potentially dangerous place. In an interview with the director of nursing (DON), on 09/15/2015 4:15 p.m., the DON reviewed Resident #152's MDS with the ARD of 08/26/15. The DON stated the MDS was inaccurate. The DON confirmed she could not find any evidence which indicated the resident was at significant risk of getting in a potentially dangerous place. In an interview, on 09/15/15 at 5:00 p.m., Social Worker (SW) #138 reviewed Resident #152's MDS with the ARD of 08/26/15. The SW stated, Yes, the minimum data set is inaccurate. c) Resident #217 On 09/16/15 at 11:30 a.m., the resident's most recent admission MDS with an ARD of 08/21/15 was reviewed. Section (E), entitled Behavior, item E1000A, indicated the resident was at risk of getting to dangerous place. At 12:08 p.m. on 09/16/15, Registered Nurse/Clinical Reimbursement Coordinator (RN/CRC) # 49, verified the MDS was incorrect. RN/CRC #49 stated the resident had not wandered into a dangerous place. At 12:30 p.m. on 09/16/15, Social Services Director #138 stated the behavior monitoring sheet for (MONTH) (YEAR) did not indicate the resident had any episodes of wandering or wandering into a dangerous place. She confirmed item E1000A of Resident #217's MDS was inaccurate. d) Resident #17 Record review, on 09/15/15 at 5:39 p.m., revealed a consultation report from the resident's urologist dated 07/23/15. The urologist diagnosed the resident with [MEDICAL CONDITION] bladder and chronic urinary tract infections (UTIs). The plan for treatment was an indwelling Foley catheter and a daily antibiotic. At 11:41 a.m. on 09/16/15, the resident's most recent MDS, an annual assessment, with an ARD of 08/19/15, was reviewed. Section I, entitled, Active Diagnosis, indicated the resident did not have a [MEDICAL CONDITION] bladder in item l1550. At 11:48 a.m. on 09/16/15, the director of nursing (DON) confirmed the MDS was inaccurate and stated the facility would do an immediate correction of the MDS.",2019-01-01
5429,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2015-09-17,278,D,0,1,C8VX11,"Based on observation, record review, and staff interview, the facility failed to ensure the quarterly minimum data set (MDS) assessment for one (1) of three (3) residents reviewed for the care area of activities of daily living (ADL) was accurate. The resident's assessment indicated the resident needed supervision with eating, but the resident did not need supervision. Resident identifier: #168. Facility census: 123 Findings include: a) Resident #168 On 09/15/15 at 3:05 p.m., review of the resident's most recent quarterly MDS, with the assessment reference date (ARD) of 07/26/15, revealed the following data: -- Section C, concerning cognitive status, indicated the resident had a Brief Interview for Mental Status (BIMS) score of fourteen (14), indicating the resident was cognitively intact. The highest possible score is 15. -- Section G, concerning functional status, indicated the resident was totally dependent during the entire seven (7) day look back period, for bed mobility, transfer, locomotion, dressing, and toileting. The portion related to eating indicated the resident needed Supervision (oversight, encouragement or cueing). Review of the previous quarterly MDS with ARD of 04/25/15 showed: -- Section C, concerning cognitive status, showed a BIMS score of fourteen (14), indicating the resident was cognitively intact. -- Section G, concerning functional status, indicated the resident was totally dependent for bed mobility, transfer, locomotion, dressing, and toileting; however, the MDS indicated the resident was independent related to eating. On 09/16/15 at 10:50 a.m., an interview with Registered Nurse (RN)/Unit Manager #103 revealed the resident had independently fed himself since admission, and had not had any decline that interfered with his ability to feed himself. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) ADL sheets, on 09/16/15 at 11:45 a.m., revealed the resident was independent with eating. On 09/16/15 at 12:58 p.m., the resident was observed in his room eating lunch without any assistance once the food tray was delivered to him. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) ADL sheets was conducted with the director of nursing (DON), on 09/16/15. The review focused on Resident #168's eating ability. The DON verified the resident was independent with eating during both months, and definitely during the seven (7) day look back periods related to the MDS. On 09/16/15 at 4:40 p.m., an interview was conducted with Clinical Reimbursement Coordinator (CRC) #49. After reviewing the resident's records, the CRC was unable to say why the MDS showed a decline in eating from independent to supervision for Resident #168. CRC #49 agreed the quarterly MDS, with an ARD of 07/26/15, was inaccurate related to the resident's eating ability.",2019-01-01
5430,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2015-09-17,309,D,0,1,C8VX11,"Based on observation, resident interview, staff interview, and record review, the facility failed to ensure care and services were provided to attain or maintain the highest practicable mental, physical, and psychosocial well-being. A random opportunity for discovery revealed the facility made no provisions to ensure Resident #36 received a meal before leaving the facility for a physician's appointment. The facility also failed to ensure the resident received a meal in a timely manner after returning from the appointment. Resident identifier: #36. Facility census: 123. Findings include: a) Resident #36 During observation of the noon meal, at 1:15 p.m. on 09/14/15, Resident #36 stated he had not had anything to eat since supper on 09/13/15. He stated he went out for a doctor's appointment around 8:30 a.m. on 09/14/15 and he was not offered anything to eat before he left. He stated, If they couldn't get me some food, I would have settled for a bowl of cereal, I am a diabetic and I need to eat, I am hungry. Further observation of the resident found the resident received his meal in his room at 2:00 p.m. on 09/14/15. At 8:35 a.m. on 09/16/15, Registered Nurse (RN) #23, a unit manager stated she knew Resident #36 did not receive a breakfast tray before he left for his appointment on 09/14/15. She said she thought the resident left around 8:45 a.m. for his doctor's appointment on 09/14/15, and returned to the facility sometime around 11:30 a.m. RN #36 was unable to provide evidence of the exact time the resident left the facility and returned. Review of the meal consumption sheets, with the administrator and RN #36 at 8:45 a.m. on 09/16/15, found the nursing assistants documented the resident consumed 100% of his morning meal on 09/14/15. RN #36 verified this documentation was untrue as she, personally knew, the resident did not get his breakfast. At 10:18 a.m. on 09/16/15, the above issue was discussed with the dietary manager and the administrator. The dietary manager verified the meal service should have begun at 7:30 a.m. on 09/14/15, and she did not know why the resident did not receive a tray. She stated the resident should have been provided an early breakfast. The administrator stated the facility was investigating the documentation of the meal consumption and plans were already made to provide food to all residents who had appointments outside the facility.",2019-01-01
5431,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2015-09-17,315,D,0,1,C8VX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility failed to ensure a resident with an indwelling urinary catheter receive care and services to prevent urinary tract infections to the extent possible. A nurse and nurse aide broke infection control protocol by leaving a Foley catheter drainage bag directly on the floor beside the resident's bed. This affected one (1) of three (3) residents observed for Foley catheter care. Resident identifier: #168. Facility census: 123 Findings include: a) Resident #168 On 08/17/15 at 1:15 p.m., review of the resident's quarterly minimum data set (MDS), with an assessment reference date (ARD) of 07/26/15, revealed Section H identified Resident #168 had an indwelling catheter and was incontinent of bowel. Resident #168 had [DIAGNOSES REDACTED]. Random observations on 09/14/15 at 5:16 p.m. and on 09/15/15 at 2:25 p.m., revealed Resident #168's Foley catheter drainage bag laying on floor beside the bed. On 09/16/15 at 9:39 a.m., the wound care nurse, assisted by Nurse Aide (NA) #86, provided wound care for Resident #168. After completion of the wound care, the bed was lowered to the lowest position making the Foley drainage bag rest on the floor. Both the wound care nurse and NA # 86 left the room leaving the Foley drainage bag resting on the floor. During an interview with Registered Nurse (RN)/Unit Manger (RNUM) #103, on 09/16/15 at 11:18 a.m., RNUM #103 went to Resident #168's room and observed the Foley catheter drainage bag. RNUM #103 observed the Foley catheter bag lying on the floor beside the resident's bed. RNUM #103 raised the bed high enough to lift the drainage bag off the floor, and agreed the drainage bag was not to be lying on the floor. She stated, I will start staff education right away. On 09/16/15 at 11:35 a.m. review of the facility's policy and procedure for care of indwelling urinary catheter revealed #10. Secure catheter tubing to keep the drainage bag below the level the patient's bladder and off the floor. Position catheter for straight drainage.",2019-01-01
5432,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2015-09-17,325,D,0,1,C8VX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random opportunity for observation, record review, resident and family interview, and staff interview, the facility failed to ensure a resident received the therapeutic diet ordered by the physician. The facility did not provide the proper consistency of liquids for a resident ordered thickened liquids prescribed due to a status [REDACTED]. Resident identifier: #242. Facility census: 123. Findings include: a) Resident #242 Observations during the Stage 1 dining observations in the Transitional Care Unit (TCU) dining room revealed nursing aide (NA) #36 having a forceful discussion with the kitchen staff member who was overseeing the steam table in the TCU dining room. NA #36 was adamant a bowl of soup was the wrong consistency for a resident, and she refused to give it to the resident because she knew it was wrong. The NA eventually took the bowl out of the dining room to a nurse at the TCU nurses station, and discussed something with the nurse. The nurse took the bowl and left the nurses station with it. On 09/14/15 at 1:01 p.m., interview with NA #36 revealed the bowl of soup was for Resident #242, and was not the right consistency. NA #36 voiced concerns that the soup broth was too thin for the type of diet the resident received. The NA stated . It was too liquid; it was just broth with no thickener. It has to be a nectar consistency. Interview with Resident #242 in her room, on 09/14/15 at 1:05 p.m., revealed the resident still had not been served lunch at that time. At 1:07 p.m. on 09/14/15, while standing outside the resident's room, observation revealed the nurse (to whom NA #36 had given the bowl of soup) returned with a bowl of soup and served it to the resident. The resident and visiting family appeared upset. The husband was observed taking the bowl to the TCU dining room. He was then observed getting a thermos and preparing a bowl of soup. When asked if there was a problem with Resident #242's lunch, the husband removed the lid off the bowl the nurse had given Resident #242, and replied Who could eat this? This would choke anybody. Observation of the bowl revealed it contained a brown extremely thick, dry pasty substance. Resident #242's husband continued to make a bowl of soup from a thermos he had brought from home. He stated, This happens all the time, that is why I bring this from home. This morning my wife had pureed egg and sausage, it was discolored with gray in the middle, and she would not eat it. The staff took it away and was supposed to bring her back something else to eat and did not. Then this is what they bring her (pointing to the bowl with the brown thick, pasty substance). On 09/14/15 at 1:20 p.m., the Administrator and the Dietary Manager were made aware of the issues Resident #242's husband revealed concerning his wife's meals. They both viewed the bowl with the brown thick, pasty substance and concluded it was broth with a thickener added to it. They said they needed to check what type of therapeutic diet the resident was on, to know if the soup broth was the correct consistency. The Administrator and the Dietary Manager said they would check into these issues and get back with their findings. The resident's minimum data set (MDS), with an assessment reference date (ARD) 08/13/15, was reviewed on 09/17/15 at 9:05 a.m. It revealed the following data: -- Section C, concerning cognitive status, indicated the resident had a Brief Interview for Mental Status (BIMS) score of nine (9), indicating moderately impaired. -- Section D, concerning mood, showed a Patient Health Questionnaire (PHQ-9) depressive screen score of four (4) indicating mildly depressed. -- Section G, concerning functional status, revealed the resident needed one person extensive assist with eating. -- Swallowing and Nutritional status in Section K revealed nutritional approaches of a mechanically altered therapeutic diet, and an admission weight of 132 lbs. -- There were no oral or dental issues noted in Section L, dental status. -- Section O revealed the resident had speech therapy, occupational therapy, physical therapy, and was on oxygen. -- Some of the resident's pertinent [DIAGNOSES REDACTED]. On 09/17/15 at 9:11 a.m., review of the current care plan showed interventions which included the need for extensive assistance with eating and a mechanical altered diet with thickened liquids due to dysphasia. The care plan indicated the resident was to be evaluated for proper diet consistency. Her nutritional status was to be monitored for changes, including changes in intake and her ability to feed herself. Staff were directed to offer alternate choices as needed and to provide her diet as ordered. On 09/17/15 at 9:23 a.m., review of medical records revealed an order for [REDACTED]. An interview with the Dietitian, on 09/17/15 at 1:52 p.m., revealed Resident #242 was stabilizing. According to the Dietitian, Resident #242 still needed all liquids at a nectar consistency. When asked if broth would be given to the resident, the Dietitian replied, Broth would have to be thickened to a nectar consistency. When asked to describe a nectar consistency, the dietitian stated, . It would be like the consistency of buttermilk. The Administrator confirmed, on 09/16/15 at 4:27 p.m., the soup broth served to Resident #242, as observed by the Administrator and the Dietary Manager on 09/14/15, was definitely much thicker than the nectar consistency prescribed for the resident.",2019-01-01
5433,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2015-09-17,329,D,0,1,C8VX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of five (5) residents whose medication regimens were reviewed for unnecessary medications, was free from unnecessary medications. The facility failed to ensure a medication was required as evidenced by specific behaviors, and failed to ensure nonpharmacologic interventions were considered and used before the use of an as needed (PRN) anti-anxiety medication. Resident identifier: #217. Facility census: 123. Findings include: a) Resident #217 Record review, at 10:30 a.m. on 09/17/15, found on 08/19/15, Resident #217 was prescribed [MEDICATION NAME] (benzodiazepine) 1 milligram (mg) PRN (as needed) for increased screaming, yelling and hitting. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. There was no evidence of behaviors which warranted the use of the [MEDICATION NAME], and no evidence of attempts at nonpharmacologic interventions prior to the use of medication. At 11:00 a.m. on 09/17/15, the director of nursing (DON) confirmed there were no documented behaviors which warranted the use of the [MEDICATION NAME] on three (3) of the five (5) days given: 08/22/15, 08/23/15 and 08/24/15. She was also unable to find evidence nonpharmacologic interventions were implemented before giving the [MEDICATION NAME].",2019-01-01
5434,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2015-09-17,364,E,0,1,C8VX11,"Based on observation, staff interview, and policy review, the facility failed to provide meals which were palatable, attractive, and at the proper temperatures at the time of receipt by the residents. Food items served from the Transitional Care Unit (TCU) were burnt, dry, and greasy. In addition, temperatures were not obtained for all foods prior to service, to ensure they were at palatable temperatures. This practice had the potential to affect all residents who received nourishment from the TCU unit, more than an isolated number of residents. Facility census: 123. Findings include: a) Noon Meal Service in the TCU Dining Room Observation of the noon meal in the TCU dining room, at 12:10 p.m. on 09/14/15, found Dietary Aide (DA) #63, serving food from a steam table located inside the dining room. At 12:52 p.m. on 09/14/15, Resident #252 told Nursing Assistant (NA) #36, she was unable to eat her lunch that was served, stating the grilled ham and cheese sandwich was burnt and the sweet potato fries were dried and burnt. NA #36 returned the plate of food to DA #63 and told him the resident could not eat her meal. Observation of the food served to Resident #252 found the resident's statements were correct. The ham and cheese sandwich was burnt on one (1) side. When served, the burnt side of the sandwich was placed with the burnt side down on the plate. The sweet potato fries were greasy, dry, and black on the outside. The Administrator (ADM) entered the TCU dining room at 1:00 p.m. on 09/14/15. She told DA #63 not to serve the rest of the ham and cheese sandwiches or the sweet potato fries from the steam table. She stated she would have the kitchen send more food. At 1:13 p.m. on 09/14/15, the Dietary Manager (DM) was asked to observe the original meal, served to Resident #63, which was still in the TCU dining room. The DM had no comment regarding the food. The DM provided a sweet potato fry from the steam table for taste testing. The DM was asked to also sample the sweet potato fries. The sweet potato fries tasted greasy, dry, and salty. The DM directed DA #63 to wait for new food to arrive from the kitchen. At 1:30 p.m. on 09/14/15, Dietary Chef Manger (DCM) #115 entered the TCU dining room with a pan containing five (5) ham and cheese sandwiches. The administrator told DCM #115 the sandwiches had to be returned to the kitchen because they were not grilled. At 1:43 p.m. on 09/14/15, grilled sandwiches and mashed potatoes arrived from the kitchen. DA #63 began preparing trays for service. The last tray was served at 2:00 p.m. to Room #212. The ADM was interviewed, at 8:08 a.m. on 09/16/15, regarding the meal service on 09/14/15. She stated the facility was rolling out new menus and working on presentation of food. The ADM stated she was taking care of the issues which occurred on 09/14/15. She said she learned the cook did not cover the sweet potatoes fries during baking, which caused them to be dry. The ADM said she did not know why the kitchen served the burnt grilled ham and cheese sandwiches, but she said this was being addressed. b) Palatable Food Temperatures On 09/14/15 at 12:30 p.m., the facility's posted menu for noon on 09/14/15 was reviewed. The menu indicated vegetable soup, tuna salad sandwich with lettuce and tomato, dilled cucumber salad, and strawberry cake were to be served at that meal. The alternative meal was hot ham and cheese sandwiches and pan fried potatoes. At 8:30 a.m. on 09/17/15, DCM #115 was asked to provide a copy of the temperature logs for the noon meal served on 09/14/15. Review of the production worksheet reports with DCM #115 found no temperatures were recorded for the tuna sandwich, which he stated was a cold food item. Temperatures were also not obtained for the grilled ham and cheese sandwich. There was a temperature for a(NAME)sandwich, which was not served, and was not on the menu. DCM #115 said the Reuben temperature was probably for the grilled ham and cheese sandwich. The DCM verified the production worksheets, used to record the temperatures of the food items, did not match the food items served for the actual meal. The dilled cucumber salad's food temperature was recorded at 50 degrees Fahrenheit (F). DCM #115 stated cold food items should not be over 40 degrees prior to service. At 8:55 a.m. on 09/17/15, the DM stated cold food should be no more than 40 degrees at the time of service. The DM also provided a copy of the 03/16/15 policy for Food Handling. The policy directed, . All Time/Temperature Control for Safety Food must maintain an internal temperature of 40 degrees F or lower and 145 degrees F or higher while being held for service .",2019-01-01
5435,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2015-09-17,371,F,0,1,C8VX11,"Based on observation, staff interview, and review of the 2013 United States Public Health Service Food and Drug Administration Food Code, the facility failed to ensure food was prepared and distributed under sanitary conditions. During food service, two (2) dietary employees were observed with full facial beards which were not contained to prevent potential food and food service item contamination from fall-out hair/whiskers. This practice had the potential to affect all residents who received food from the Transitional Care Unit (TCU) unit, more than a limited number of residents. Facility census: 123. Finding include: a) Meal observation in the TCU dining room During observation of the noon meal in the TCU dining room, from 12:10 a.m. to 1:55 p.m. on 09/14/15, Dietary Aide (DA) #63 was observed serving food from a steam table located inside the TCU dining room. He had a full beard and was not wearing a beard restraint. At approximately 12:45 p.m., Chef Manager (CM) #115, entered the serving area wearing only a hair net. He also had a full beard. At 12:52 p.m. on 09/14/15, the dietary manager was asked if she expected her employees to wear a beard restraint if they had a full beard. She stated, if their beard was trimmed she did not expect them to wear a covering. She stated, It's just like eyebrows, you don't cover them. b) 2013 Food Code 2-402.11 Effectiveness. -- (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. -- (B) This section does not apply to food employees such as counter staff who only serve beverages and wrapped or packaged foods, hostesses, and wait staff if they present a minimal risk of contaminating exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.",2019-01-01
5436,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2015-09-17,428,D,0,1,C8VX11,"Based on record review and staff interview, the facility failed to act upon the pharmacist's recommendation for one (1) of five (5) residents reviewed for unnecessary medications. The physician failed to provide a clinical rationale for not attempting gradual dose reductions (GDRs) and/or discontinuance of medications as recommended by the pharmacist. Resident identifier: #60. Facility census: 123. Findings include:a) Resident #60 A review of Resident #60's medical record, on 09/17/15 at 11:26 a.m., revealed the resident had been on the medication Abilify four (4) milligrams (mg) daily since (MONTH) 2014. A GDR occurred for the Abilify, to two (2) mg daily in (MONTH) 2014, and then another gradual dose reduction occurred in (MONTH) (YEAR) to one (1) mg. Resident #60 had also been taking Depakote five-hundred (500) mg two (2) times a day, Ativan half (0.5) mg three (3) times a day, and Paxil twenty (20) mg one (1) time a day since (MONTH) 2013. A review of Resident #60's pharmacist consultation report, on 09/17/15 at 11:37 a.m., revealed the pharmacist made recommendations on 10/14/14, 01/12/15 and 04/08/15. The recommendations stated, If Abilify, Depakote, Paxil, and Ativan are to remain at current doses, please document the rationale for current regimen. The physician accepted the recommendation related to the Abilify gradual dose reduction on 10/14/14, to consider a trial reduction of Abilify from four (4) milligrams (mg) qd (every day) to two (2) mg at night (HS), and a gradual dose reduction (GDR) of the Abilify from two (2) mg to one and half (1.5) mg at HS on 01/12/15. On 04/08/15, the pharmacist made a recommendation to discontinue the Abilify; but the physician declined the recommendation. There was no clinical rationale documented by the physician for continuing the Abilify. In addition, the physician did not document the clinical rationale for continuing the Depakote, Paxil, and Ativan, at their current doses, as recommended by the pharmacist on 10/14/14, 01/12/15 and 04/08/15. An interview was conducted with the director of nursing (DON), on 09/17/15 at 11:30 a.m., regarding the pharmacist's recommendations for the resident. The DON was asked if the physician provided a rationale for continuing the Depakote, Paxil, and Ativan at their current doses, as recommended by the pharmacist on 10/14/14, 01/12/15, and 04/08/15. In addition, the DON stated the physician did not provide a rationale for continuing the medications. She stated the physician did a GDR on the Abilify two (2) times, but the physician did not document the rationale for continuing the Abilify, as recommended by the pharmacist on 04/08/15. .",2019-01-01
5437,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2015-09-17,463,D,0,1,C8VX11,"Based on observation and staff interview, the facility failed to ensure the call light system was functioning for one (1) of forty (40) residents reviewed in Stage 1 of the Quality Indicator Survey (QIS). Resident identifier: #87. Facility census: 123. Findings include: a) Resident #87 On 09/14/15 at 6:00 p.m., during Stage 1 observations of Resident #87's room, the resident's call bell did not work. (This resident was able to use the call bell.) Maintenance was immediately notified of the issue. At 6:06 p.m. on 09/14/15, the maintenance department replaced the call bell cord with a functioning cord. The administrator was notified and an audit of all call bells was performed.",2019-01-01
5438,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2015-09-17,502,D,0,1,C8VX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain timely laboratory services for one (1) of five (5) residents reviewed for unnecessary medications. The facility failed to obtain a [MEDICATION NAME] ([MEDICATION NAME] Acid) level. Resident identifier: #60. Facility census: 123. Findings include: a) Resident #60 On 09/17/15 at 12:30 p.m., a review of physician's orders [REDACTED]. The level was due every (MONTH) and October. A review of Resident #60's record found no laboratory result for a Valporic Acid ([MEDICATION NAME]) level in (MONTH) (YEAR). In an interview with the director of nursing (DON) on 09/17/15 at 1:25 p.m., when asked whether Resident #60 had a Valporic Acid level collected in (MONTH) (YEAR), the DON confirmed the resident did not have the level done in April. The DON stated, We are going to collect a Valporic Acid level now.",2019-01-01
6492,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,157,D,0,1,3WT411,"Based on record review, review of the facility's protocol for standing orders, and staff interview, the facility failed to inform the physician after a change in health status for one (1) of five (5) residents reviewed during the unnecessary medication review. The physician was not notified when Resident #48 had pain symptoms for more than twenty-four (24) hours. Resident identifier: #48. Facility census: 123. Findings include: a) Resident #48 1. Review of Resident #48's Medication Administration Record [REDACTED]. 2. Review of the whenever needed (PRN) pain management flow record, on 06/18/14 at 10:00 a.m., revealed on 06/12/14 the (time was not legible), the pain rating was 3-4, the location was knee, and the medication and dose was Tylenol 650 mg. The PRN pain management flow record was left blank for non-pharmacological treatment, pain rating, level of sedation and initials. The resident received the same dosage of Tylenol on 06/13/13, but the PRN pain management flow sheet was left blank. There was no indication the Tylenol was administered for fever. 3. An interview was conducted on 06/18/14 at 11:00 a.m., with Employee #98 licensed practical nurse (LPN). When LPN #98 reviewed the PRN pain management flow sheet, she stated LPN #51 administered the Tylenol on 06/12/14 for knee pain. For the Tylenol administered on 06/13/14 at 2:00 p.m., LPN #98 confirmed LPN #51 should have documented something on the PRN pain management flow sheet for the reason she administered the Tylenol on 06/13/14. 4. In an interview with LPN #51 on 06/19/14 at 7:50 a.m., when asked why the PRN pain management flow sheet was not filled out, she stated she just did not fill the information in correctly for 06/12/14 and 06/13/14. She stated the Tylenol was given for knee pain on both days. She said the resident had just received therapy and her knee was hurting. When LPN #51 was asked to review the MAR for the reason the Tylenol was given on both days, she stated, This order is for fever. She confirmed she did not notify the physician for the pain symptoms persisting more than twenty four (24) hours per the facility's protocol for standing orders. 5. Review of the facility's protocol for standing orders for Tylenol for mild pain on 06/19/14 at 8:00 a.m., revealed If symptom persist more than 24 hours, notify MD (medical doctor).",2018-03-01
6493,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,166,E,0,1,3WT411,"Based on record review, review of complaints filed with the Office of Health Facility Licensure and Certification, staff interview, confidential interview, and resident interview, the facility failed to make efforts to promptly resolve grievances voiced by the residents. One (1) of two (2) off site complaints investigated concurrently with the Quality Indicator and Licensure Surveys contained an allegation call lights were not being answered timely. During Stage 1 of the Quality Indicator Survey (QIS), one (1) of twenty-five (25) sample residents interviewed voiced a concern about the call lights not being answered timely. Eight (8) of ninety-six (96) Record of Customer and Family Concerns (grievances) filed with the facility in the previous twelve (12) months identified a problem of call lights not being answered timely. This practice had the potential to affect all residents who used their call lights to summon assistance. Resident Identifiers: #234, #233, #232, #231, #229, #228, #200, #50 and #201. Facility Census: 123. Finding include: a) Off Site Complaint On 06/02/14, the State Agency (OHFLAC) received a complaint alleging it took staff 30 to 45 minutes to answer resident call lights. In a confidential interview at 10:25 a.m. on 06/19/14, the complainant again said it took staff 30 to 45 minutes to answer the residents' call lights. The complainant stated he/she would sometimes have to go find someone to help the resident because they would not answer the call light. According to the complainant, the staff had been told about this concern, but the facility never really did anything to resolve the problem. b) Resident #50 During a Stage 1 interview with Resident #50 at 3:06 p.m. on 06/10/14, when asked if she received the care and assistance she needed without having to wait a long time, she stated, No, because she sometimes had to wait a long time for them to answer her call light. She was unable to say how long it took staff to answer her call light, but stated she had to wait longer than she should have to wait. c) Resident concerns Review of the facility's Record of Customer and Family Concerns, at 11:00 a.m. on 06/12/14, found eight (8) concerns related to call lights not being answered timely by facility staff. The concerns were: 1) Resident #229 A concern form, dated 06/20/13, identified the resident's concern was, Resident stated she has been waiting on call light for 20 mins. (minutes). The action taken by the facility was to check call lights and provide education to the staff to answer the call lights quickly. Attached to the grievance was a form titled Call Light Checks, completed by Guest Service Director (GSD) #86 on 06/28/13. This form indicated the GSD had checked the call lights in four (4) random rooms between the times of 10:34 a.m. and 11:00 a.m. on 06/28/13. It took the staff no more than 17 minutes to answer each call light that was randomly selected. The GSD documented he followed up with the resident and the resident was happy with the actions taken by the facility. 2) Resident #231 On 07/10/13, Resident #231's concern was identified as, Resident stated that he was waiting on a CNA (certified nursing assistant) for a really long time when resident turned on call light. The action taken by the facility was to check call lights. Attached to the concern was a form titled Call Light Checks. This form, completed by the GSD on 07/10/13, indicated the GSD had checked the call lights in three (3) random rooms between the times of 2:31 p.m. and 3:05 p.m. It took staff no more than five (5) minutes to answer each call light checked. The GSD documented he had followed up with Resident #231 and he was happy with the actions taken. 3) Resident #232 A concern form dated 11/11/13, identified a concern of, Resident's family stated that it took too long to answer call light. The action taken by the facility was to check call lights. Attached to the concern was a form titled Call Light Checks. This form, completed by Employee #86, GSD on 11/13/13, indicated the GSD had checked the call lights in four (4) random rooms between the times of 1:34 p.m. and 1:41 p.m. It took staff no more than one (1) minute to answer each call light checked. The GSD documented he had followed up with Resident #232 and he was happy with the actions taken to resolve this resolution. 4) Resident #233 A concern form dated 11/13/13, identified the resident's concern as, Resident informed GSD that call lights are not being answer(ed) timely. The action taken by the facility was to check call lights. Attached to the concern was a form titled Call Light Checks. This form, completed by the GSD on 11/13/13, indicated the GSD had checked the call lights in four (4) random rooms between the times of 1:34 p.m. and 1:41 p.m. It took staff no more than one (1) minute to answer each call light checked. This was the same form which was attached to the concern dated 11/11/13. The GSD documented he had followed up with Resident #233 and she was happy with the actions taken. 5) Resident #234 On 11/13/13, this resident's concern was identified as, Resident stated that call lights are not being answered timely. The action taken by the facility was to check call lights. Attached to the concern was a form titled Call Light Checks. This form, completed by the GSD on 11/13/13, indicated the GSD had checked the call lights in four (4) random rooms between the times of 1:34 p.m. and 1:41 p.m. It took staff no more than one (1) minute to answer each call light checked. This was the same form which was attached to the concerns for Residents #232 and #233 on 11/11/13 and 11/13/13 respectively. The GSD documented he had followed up with Resident #234 and she was happy with the actions taken. 6) Resident #200 A concern dated 03/18/14 for Resident #200, identified the resident's concern as, Call lights. The action taken by the facility was to check call lights. Attached to the concern was a form titled Call Light Checks. This form, completed by the GSD on 03/18/14, indicated the GSD had checked the call lights in three (3) random rooms between the times of 2:29 p.m. and 2:42 p.m. It took staff no more than two (2) minutes to answer each call light checked. The GSD documented the follow up as GSD pulled call lights. The form did not indicate whether Resident #200 was satisfied with the facility's actions to resolve this concern. 7) Resident #201 This resident's concern, dated 05/09/14, was, Resident is cont. (continually) waiting up to 15 min. to have call light answered, causing resident to have episodes of incont. (incontinence). The action taken by the facility was to check call lights on evening shift. Attached to the concern was a form titled Call Light Checks. This form, completed by the GSD on 05/12/14, indicated the GSD had checked the call lights in four (4) random rooms between the times of 1:54 p.m. and 2:36 p.m. It took staff no more than two (2) minutes to answer each call light checked. The GSD had not documented he had followed up by pulling the call lights, however he did document whether Resident #201 was satisfied with this action. The form indicated the call lights would be checked on evening shift, but in fact the call lights were checked during day shift. 8) Resident #228 According to a concern form dated 06/02/14, Resident #228 had complained, He waited 45 mins. on his call light. The action taken by the facility was to check call lights. There was no form attached to this concern form to indicate the GSD had checked the call lights. The GSD documented he had followed up with Resident #228 and she was happy with the actions taken. During an interview with the GSD at 2:36 p.m. on 06/18/14, he stated when there was a concern with call lights, he would randomly pull call lights and determine the response time. He stated he had done this numerous times and he tried to do it around meal times when the aides were the busiest. When asked how he determined what shift to randomly pull the call lights on, he stated he mostly did it on day shift around meal times unless the concern form indicated it happened on a different shift. When asked whether he spoke to the residents prior to pulling the call lights to determine what shift the lights were not being answered on, or to determine if it was more prevalent when specific staff were working, he stated he did not speak to the residents prior to pulling the call lights. He stated he just went by what the concern form indicated and it usually did not indicate what shift the call lights were not being answered on. The eight (8) concerns were reviewed with the GSD and he confirmed the call lights were all randomly checked during day shift. When asked how he determined whether the concern had been resolved or not, the GSD stated he would just go tell the resident he pulled the call lights and would advise them of the response time the staff had in answering the lights. Then he would ask them if they were happy with the resolution. He stated they seem to always be satisfied with this response to these concerns. d) During an interview at 3:52 p.m. on 06/18/14, the Nursing Home Administrator (NHA), was asked how they resolved concerns related to call lights being answered timely. She stated the GSD would randomly pull call lights and record the time to determine if it was truly taking too long to answer the residents call light. When asked how they determined on which shift or what time of the day to pull the call lights, she stated it would depend on what shift the resident had concerns with. She was asked to review the concerns and the recorded call light checks to determine if they were checked on the appropriate shift. She confirmed all the call light checks were completed on day shift and she did not see where the GSD had attempted to determine what shift the resident had concerns with. She stated she could start having him to do a root cause analysis with the concerns to determine if it was a specific shift or when a specific staff member was working.",2018-03-01
6494,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,167,C,0,1,3WT411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to make the results of the most recent survey of the facility by Federal or State surveyors, and any plan of correction in effect, available for examination. The facility also failed to post a notice of the availability of the survey results in a readily accessible place. This practice had the potential to affect all residents and visitors wishing to review this information. Facility census: 123. Findings include: a) Upon initial entrance to the facility on [DATE] at 9:45 a.m., the binder containing the survey results and/or notice could not be located. Employee #42, the director of nursing (DON) was approached about the inability of the surveyor to locate the survey results and/or the notice as to the location of the survey results. The DON said the results were in a black binder located in the bookcase in the front lobby. The binder had a small white label noting Survey. When asked where the notice indicating the location of the survey results could be located, the DON found the notice was obscured in a corner of the bookcase in the front lobby.",2018-03-01
6495,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,225,F,0,1,3WT411,"Based on personnel record review, review of the requirements for criminal background checks in West Virginia, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility did not make reasonable efforts to uncover information about any past criminal prosecutions by the use of fingerprinting, which is a required procedure to ensure a statewide criminal background check in West Virginia. This was true for four (4) of ten (10) employees whose files were reviewed. This had the potential to affect all residents residing in the facility. Employee Identifiers: #133, #101, #91, and #48. Facility census: 123. Findings include: a) Thorough Criminal Background Checks Review of personnel files, on 06/17/14, between 1:00 p.m. and 1:24 p.m., found no evidence of fingerprints being taken as required for a West Virginia criminal background check for four (4) employees. These were: 1. Nursing Assistant (NA) #133, hired on 04/02/14. 2. NA #101, hired on 08/14/12. 3. NA #91, hired on 09/27/11. 4. NA #48, hired on 12/21/05. In a discussion with the Nursing Home Administrator (NHA) at 2:07 p.m. on 06/23/14, she confirmed Nurse Aides #133, #101, #91, and #48 did not have background checks completed using fingerprints in their personnel files. When asked what the process was to complete background checks for employees, she stated if they had not lived, worked, or gone to school out of state, they would submit the employees' fingerprints for a background check for the State of West Virginia. She also stated, if the employee had worked, lived, or gone to school out of state, they would submit the employees' fingerprints to the State of West Virginia and to the Federal Bureau of Investigations (FBI) for a background check. To ensure the facility had not employed an individual who had been found guilty of abusing, neglecting, or mistreating residents by a court of Law, West Virginia requires submission of fingerprints to the agency contracted by the West Virginia State Police.",2018-03-01
6496,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,241,D,0,1,3WT411,"Based on observation, staff interview, confidential interview, and resident interview, the facility failed to maintain dignity during dining for one (1) of six (6) residents reviewed for Activities of Daily Living (ADLs) during Stage 2 of the Quality Indicator Survey. Resident #3 was not provided needed assistance to maintain dignity with dining. Resident Identifier: #3. Facility Census: 123. Findings Include: a) Resident #3 A confidential interview during Stage 1 of the Quality Indicator Survey on 06/11/14 at 2:43 p.m., revealed Resident #3 did not receive the assistance she needed with her meals. The person stated Resident #3 could not see well and she sometimes would not get the food from her plate to her mouth, or she would not get any food on her utensil, but would put the utensil to her mouth as if she had food on it. The interviewee stated this had been mentioned to the staff, but felt staff did not assist the resident as they should. Observation of the breakfast meal on 06/19/14, in the south hall dining room, revealed Resident #3 received her food at 7:46 a.m. Resident #3 was very lethargic and kept dozing off while trying to feed herself. She was awakened at 7:53 a.m. and offered something to drink. She was given a cup of coffee, and then dozed off again. At 7:58 a.m., Resident #3 had dozed off multiple times while attempting to feed herself bites of food. At 7:59 a.m., Resident #3 dropped her fork while trying to take a bite of food. The fork hit the floor and she was left with no utensils because, previously, at 7:55 a.m., she had dropped her spoon onto her lap after she dozed off while trying to take a bite of oatmeal. At 8:00 a.m., Resident #3 was observed reaching around the edge of her bowl and her plate feeling for utensils. She then dozed off again. At 8:02 a.m., she was again observed reaching for her utensils around the edge of her plate and the edge of her bowl. At 8:03 a.m., Resident #3 was observed holding her bowl of oatmeal in her left hand and was observed eating the oatmeal out of the bowl with her right hand. She then dozed off again and spilled the bowl of oatmeal onto her lap. She sat the bowl back on the table and was eating the oatmeal off her lap with her fingers. She then found the spoon which she had dropped onto her lap earlier, picked it up, and proceeded to eat the oatmeal off her lap using her spoon. At 8:07 a.m., a nurse aide was observed looking at Resident #3, but offered no help or assistance. At 8:11 a.m., LPN #51 went up to Resident #3 and stated, Here is your coffee. At that time, Resident #3 began to drink her coffee, which was served to her at 7:53 a.m. At 8:15 a.m., LPN #51 sat by Resident #3 and turned the resident's plate so she could more easily reach the remaining food on her plate. The resident again dozed off and dropped a spoonful of oatmeal on her lap. She then roused and ate the food she had dropped on her lap with her spoon. All while LPN #51 sat and watched Resident #3. LPN #51 then asked Resident #3 if she was finished and Resident # 3 replied, Yes. LPN #51 removed the plate from the table at 8:20 a.m. At 8:22 a.m., Resident #3 and the area where she had eaten were observed. She had oatmeal on her pants where she had spilled her bowl of food. The floor to the left of the resident had food on it where she had dropped her food without being able to get it to her mouth. The table had coffee on it where the resident had spilled her coffee. Resident #3 was asked how she was doing, to which she replied, I am pretty sleepy. During an interview with Registered Nurse (RN) #77 at 8:28 a.m. on 06/19/14, when asked if Resident #3 typically needed assistance with eating, she stated, She usually does very well. She observed Resident #3, who was still sitting in the dining room, and stated, She sure is a mess this morning. It does not look like she did very well this morning. At 8:33 a.m. on 06/19/14, LPN #51 stated Resident #31 seemed sleepy that morning and she usually did better than she did that morning. She continued to state to RN #77, I was sitting beside her when she dropped the one bite off her spoon.",2018-03-01
6497,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,243,E,0,1,3WT411,"Based on the resident council president interview and staff interview, the facility failed to inform the resident council they could meet privately without facility staff in attendance. This had the potential to affect more than an isolated number of residents. Resident identifier: #50. Facility census: 123. Findings include: a) Resident #50 In an interview with Resident #50 on 06/12/14 at 11:52 a.m., when asked whether she could meet privately without facility staff in attendance for the resident council meeting if desired, she stated she did not know if the council could meet without staff present. b) During an interview with Activities Director (AD) #30, on 06/16/14 at 1:15 p.m., when asked whether she had discussed with the resident council whether they could have a resident council meeting without the facility staff in attendance, she replied she had not. c) On 06/19/14 at 2:00 p.m., the Administrator was informed the resident council was not informed of the right to have a resident council meeting privately without facility staff in attendance. She said the AD had informed her of this already.",2018-03-01
6498,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,244,E,0,1,3WT411,"Based on interview with the resident council president, staff interview, and a review of the resident council meeting minutes for a period of five (5) months, the facility failed to ensure concerns expressed by members of the resident council related to operational decisions affecting their care were viewed and acted upon. This practice had the potential to affect more than an isolated number of residents. Facility census: 123. Findings include: a) On 06/12/14 at 11:52 a.m., during an interview with the Resident Council President (RCP), Resident #50, she revealed the facility had not responded to the council members concerns. Resident #50 stated the staff did not address call lights not being answered, French fries being hard, the request to have additional toppings for hot dogs, and medication not being given in a timely manner. She was asked if the resident council minutes could be reviewed, and replied, Yes, you can review the resident council minutes. A review of the resident council minutes on 06/12/14 at 2:00 p.m., revealed repeated concerns for staff not answering call lights, and medication being passed out in a timely manner. There were two (2) concerns that were not addressed related to French fries being hard and the resident council's request for additional hot dog toppings the residents did not receive. 1) A review, on 06/16/14 at 11:00 a.m., of the resident council concerns for January 2014 found a concern about nursing staff not answering call lights for one resident. On 06/16/14 at 11:05 a.m., the department response form revealed the concern was addressed by Guest Services Director (GSD) #86 and the Activities Director (AD) #30. It was noted the GSD and AD informed the resident that staff did answer the resident's call light. In an interview with the GSD and the AD, on 06/16/14 at 2:30 a.m., when asked which resident had complained, neither could identify who the resident was and could not provide any information concerning their discussion with the resident. GSD #86 provided a call light audit dated 02/04/13 - nearly a year prior to the resident's complaint. The AD said she did not give the department response form to the nursing department for the call light concern, so the nursing staff did not know to follow up on the resident's concern. 2) On 06/16/14 at 11:10 a.m., review of the resident council concerns for February 2014 found a concern regarding nursing staff not answering call lights. The department response form for the staff not answering call lights was, GSD had done a call light check. In an interview on 06/16/14 at 2:30 p.m., the GSD was asked to provide the call light audit. The GSD did not provide a call light audit as of the time of exit on 06/23/14. 3) A review of resident council concerns for March 2014, on 06/16/14 at 11:20 a.m., found concerns were voiced related to medications not being passed out in a timely manner. The resident council had also requested additional hot dog toppings, like chili, slaw, and onions. The department response form for medications not being passed out in a timely manner revealed the concern was not addressed for March 2014. The Dietary response for the request for additional hot dog toppings was that a new Spring/Summer menu would be rolled out in April and Will do menu addition to Hot Dog meals with RD (registered dietitian) approval of menu changes and Chili and Slaw will be added. In an interview with the GSD on 06/16/14 at 12:15 p.m., when asked how the staff responded to the residents' concern related to medication not being passed out in a timely manner, he stated he would do an audit sometimes. The GSD said he was not aware of the residents having a concern about medication not being passed out in a timely manner. During an interview on 06/16/14 at 11:40 a.m., the Dietary Director (DD) #102 was asked whether the residents received the hot dog toppings they requested. She stated the additional hot dog toppings were to be on the menu for April 2014, but she did not know why they were not offered. 4) The resident council minutes for April 2014, reviewed on 06/16/14 at 11:25 a.m., identified resident concerns related to medication not being passed out in a timely manner and French fries being hard. The department response form for the medication not being passed out in a timely manner revealed the concern was not addressed on the department response form for April 2014. The response from the dietary department regarding the French fries was, French Fries are difficult to keep at temperature. Will test batch cooking to see if temps improve any. If no improvement is found, then will consider a menu substitution. Check food temps from the meal; (4/22 lunch), food temps were recorded and accurate. Will audit food temps throughout the service to make sure heat wells are keeping food hot during the entire meal service. In an interview with the AD on 06/16/14 at 2:30 p.m., when asked what the response to the concern about medications not being given timely was, she stated, this was not addressed, she had forgotten to give the nursing department a response form for the concern related to medication not being passed out in a timely manner for March and April 2014. During an interview on 06/16/14 at 11:40 a.m., the Dietary Director (DD) #102 stated she had no evidence she had addressed the concern about the French fries being hard. She stated she had made a comment on the response form, but had no evidence the response was done. 5) A review of the resident council minutes for May 2014 revealed a concern about medication not being passed out in a timely manner. A review of the department response form dated 05/27/14, revealed Employee #42, the director of nursing (DON) asked the AD which resident complained about the medication being passed out more than an hour late. The AD was unable to tell the DON who the resident was who made the complaint. The DON stated that the RCP was asked about the concern of the medication not being passed in a timely manner, and the RCP stated medications were being passed late on night shift occasionally, and stated one nurse's name. The DON explained to the RCP that she would do some education with night shift on north hall about medication times. The RCP stated that was a great idea. In an interview on 06/16/14 at 4:00 p.m., the Director of Nursing (DON) #42 was asked to provide the education note given to night shift nurses about medication times. As of the time of exit on 06/23/14, no evidence of the education given to the night shift nurses was provided. b) During an interview on 06/19/14 at 4:15 p.m., the Administrator was informed of the resident concerns that were identified in the resident council meetings and were not addressed. She stated the AD had told her it was Okay. She did not provide any additional information.",2018-03-01
6499,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,246,D,0,1,3WT411,"Based on observation and staff interview, the facility failed to ensure accommodation of the need for access to a call light for one (1) of forty (40) census sample residents. The resident's call light was not accessible. Resident identifier: #226. Facility census: 123. Findings include: a) Resident #226 Observation, on 06/10/14 at 3:05 p.m., revealed Resident #226 was seated in her wheelchair at the foot of her bed in her room. The call light was observed under the bed and was unable to be removed from its position. It was not accessible to the resident. During an interview on 06/10/14 at 3:15 p.m., Employee #151, occupational therapist (OT), verified the call light was positioned under the resident's bed and was not accessible to the resident. In an interview on 06/10/14 at 3:30 p.m., Employee #54, Unit Manager/ Assistant Director of Nursing (ADON), confirmed all residents should have their call lights within reach at all times.",2018-03-01
6500,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,253,F,0,1,3WT411,"Based on observation, resident interview, and staff interview, it was determined the facility failed to ensure effective housekeeping and maintenance services. The physical environment was not in good repair. The resident rooms had rusted bathroom cabinets, soiled privacy curtains, soiled floors, holes in walls, missing paint and scrapes on the walls, gloves and trash on the floors, missing cove molding, and soiled resident care equipment. This practice affected sixty (60) of sixty (60) rooms observed during Stage 1 and Stage 2 of the Quality Indicator Survey. This practice had the potential to affect all residents. Room identifiers: #100, #101, #102, #103, #104, #105, #106, #107, #108, #111, #112, #113, #114, #115, #116, #117, #118, #119, #120, #121, #122, #123, #124, #200, #201, #202, #204, #205, #206, #207, #208, #209, #210, #211, #212, #213, #214, #215, #216, #217, #218, #219, #220, #221, #222, #303, #307, #309, #310, #311, #312, #313, #314, #315, #316, #317, #318, #319, #320, and #321. Resident identifiers: #39, #117, and #222. Facility census: 123. Findings include: a) Observations of the facility, during Stage 1 and Stage 2 of the Quality Indicator Survey, revealed the following rooms had maintenance and/or housekeeping concerns: 1. The following resident rooms had rusty cabinets in the bathrooms: #100, #101, #102, #103, #104, #105, #106, #107, #108, #111, #112, #113, #114, #115, #116, #117, #118, #119, #120, #121, #122, #123, #124, #200, #201, #202, #204, #205, #206, #207, #208, #209, #210, #211, #212, #213, #214, #215, #216, #217, #218, #219, #220, #221, #222, #303, #307, #309, #310, #311, #312, #313, #314, #315, #316, #317, #318, #319, #320, and #321. 2. Room 101 - The cove molding was missing in sections of the room. 3. Room 103 - The ceiling above bed A was stained. 4. Room 107 - The ceiling was cracked above bed B. 5. Room 110 - The floor was stained yellow and red. 6. Room 116 - There were two (2) holes in the wall beside the bathroom sink. The floor was stained yellow and brown. 7. Room 119 - The floor was stained with a brown substance. 8. Room 122 - The walls had areas of paint peeling. The bathroom door was scratched and stained brown. 9. Room 123 - There were three (3) holes in the wall under the television. 10. Room 202 - The ceiling above bed A had a crack. 11. Room 205 - The wall by the window had multiple black scuff marks. 12. Room 206 - The floor in the room was stained red and brown. 13. Room 209 - The floor in the room was stained brown in several areas. 14. Room 211 - There were multiple black scrapes and scuffs on the bathroom walls. 15. Room 216 - The floor in the room was stained brown in several areas. 16. Room 303 - The ceiling above bed B had a red stain. 17. Room 307 - The room had holes in the wall behind television. 18. Room 309 - The room had several holes in the walls. 19. Room 313 - The privacy curtain had broken hooks. 20. Room 316 - The door facing to the bathroom was scratched in multiple areas. b) During the initial tour of the facility, on 06/12/14 at 8:00 a.m., the following housekeeping concerns were identified: 1. Room 102 - Wet paper towels and four (4) pairs of gloves were on the bathroom floor. 2. Room 104 - There were two (2) gloves and a wet wash cloth on the floor. 3. Room 107 - A wet wash cloth was lying on floor. 4. Room 110 - There were three (3) gloves on the bathroom floor. 5. Room 119 - The floor was sticky. 6. Room 124 - The floor was sticky and covered with food in several areas. There was a wet paper towel on the floor at the foot of bed B. 7. Room 206 - The bathroom had six (6) gloves (inside-out) and two (2) wet wash cloths on the floor. There were large pieces of food in several places on the floor. 8. Room 209 - A large wet bath towel was on the bathroom floor. 9. Room 307 - The privacy curtain was stained brown in several areas. 10. Room 309 - The privacy curtain had multiple stains. 11. Room 313 - The privacy curtain was stained brown in several areas. 12. The floor of the wheelchair scale on the Transitional Care Unit was covered with food and soiled with a brown substance. c) Residents #117 and #222 These residents were interviewed on 06/12/14 at 8:30 a.m. They said their room was always dirty. d) The Director of Nursing (DON) was interviewed on 06/12/14 at 8:45 a.m. The DON stated she was aware of the housekeeping issues and was directing the staff to do their best. e) In an interview on 06/12/14 at 10:30 a.m., the Housekeeping Director revealed he was aware of the housekeeping/maintenance issues in all rooms. The director stated he was new to the facility and was doing the best he could. f) Resident #39 Observation on the the north hall on 06/12/14 at 9:00 a.m., found a wheelchair belonging to Resident #39 had a foot buddy lying on the footrest of the chair. The foot buddy was heavily soiled with food. A second observation of the resident's wheelchair and foot buddy, on 06/17/14 at 12:05 a.m., accompanied by Licensed Practical Nurse (LPN) #73, found the foot buddy remained heavily soiled. LPN #73 stated the food buddy needed to be cleaned.",2018-03-01
6501,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,272,E,0,1,3WT411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete the required documentation for the care area assessments and triggers for twenty-three (23) of forty-one (41) residents whose Minimum Data Set (MDS) assessments were reviewed in Stage 2 of the Quality Indicator Survey (QIS). The Care Area Assessment (CAA) Summary, Section V of the MDS 3.0., nor the CAA documentation, provided the location and dates for the information used to complete the additional assessment for triggered areas. For Resident #3, the facility failed to accurately complete an assessment to address the resident's contractures. Resident identifiers: #27, #138, #55, #226, #132, #171, #33, #11, #133, #18, #38, #5, #32, #19, #36, #90, #124, #83, #76, #117, #225, #48, and #3. Facility census: 123. Findings include: a) Residents #27, #138, #55, #226, #132, #171, #33, #11, #133, #18, #38, #5, #32, #19, #36, #90, #124, #83, #76, #117, #225, #48, and #3 Review of the MDSs for these residents found Section V, the CAA Summary, nor the CAA worksheets, identified the source, location, and date of the information utilized to complete the additional assessment of the triggered areas. In an interview with Employee #67, registered nurse (RN) - clinical reimbursement coordinator (CRC), on 06/12/14 at 11:00 a.m., she confirmed the CAA worksheets did not contain the source, location and date of the information utilized to complete the CAAs. The residents, the dates of the assessments, and the areas triggered were: 1) Resident #27 Review of the resident's medical record, on 06/12/14 at 10:15 a.m., found a MDS with an ARD of 08/14/13. Review of the CAA summary, Section V, found the assessment had triggered the care areas of visual function, activity daily living (ADL) functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, dehydration/fluid maintenance, pressure ulcers, and [MEDICAL CONDITION] drug use. 2) Resident #138 Review of the resident's medical record, on 06/12/14 at 11:15 a.m., found a MDS with an ARD of 01/16/14. Review of the CAA summary, Section V, found the assessment had triggered the care areas of cognitive loss/dementia, activity daily living (ADL) functional/rehabilitation potential, urinary incontinence and indwelling catheter, behavioral symptoms, falls, dehydration/fluid maintenance, dental care, pressure ulcers, and [MEDICAL CONDITION] drug use. 3) Resident #55 Review of the resident's medical record, on 06/12/14 at 11:45 a.m., found a MDS with an ARD of 10/07/13. Review of the CAA summary, Section V, found the assessment had triggered the care areas of cognitive loss/dementia, communication, psychosocial well-being, mood state, behavioral symptoms, and activities. 4) Resident #226 Review of the resident's medical record, on 06/16/14 at 1:15 p.m., found a MDS with an ARD of 06/06/14. Review of the CAA summary, Section V, found the assessment had triggered the care areas of visual function, urinary incontinence and indwelling catheter, falls, pressure ulcers, and [MEDICAL CONDITION] drug use. 5) Resident #132 Review of the resident's medical record, on 06/16/14 at 1:45 p.m., found a MDS with an ARD of 02/06/14. Review of the CAA summary, Section V, found the assessment had triggered the care areas of cognitive loss/dementia, activity daily living (ADL) functional/rehabilitation potential, urinary incontinence and indwelling catheter, psychosocial well-being, behavioral symptoms, activities, falls, dehydration/fluid maintenance, pressure ulcers, and [MEDICAL CONDITION] drug use. 6) Resident #171 Review of the resident's medical record, on 06/16/14 at 2:30 p.m., found a MDS with an ARD of 11/04/13. Review of the CAA summary, Section V, found the assessment had triggered the care areas of activity daily living (ADL) functional/rehabilitation potential, urinary incontinence and indwelling catheter, psychosocial well-being, falls, dehydration/fluid maintenance, pressure ulcers, [MEDICAL CONDITION] drug use, and pain. 7) Resident #33 Review of the resident's medical record, on 06/16/14 at 3:00 p.m., found a MDS with an ARD of 05/16/14. Review of the CAA summary, Section V, found the assessment had triggered the care areas of activity daily living (ADL) functional/rehabilitation potential, urinary incontinence and indwelling catheter, psychosocial well-being, falls, pressure ulcers, and [MEDICAL CONDITION] drug use. 8) Resident #11 Review of the resident's medical record, on 06/17/14 at 1:00 p.m., found a MDS with an ARD of 11/22/13. Review of the CAA summary, Section V, found the assessment had triggered the care areas of cognitive loss/dementia, communication, psychosocial well-being, mood state, behavioral symptoms, and activities. 9) Resident #133 Review of the resident's medical record, on 06/17/14 at 1:45 p.m., found a MDS with an ARD of 03/13/14. Review of the CAA summary, Section V, found the assessment had triggered the care areas of activity daily living (ADL) functional/rehabilitation potential, urinary incontinence and indwelling catheter, psychosocial well-being, falls, nutrition, dehydration/fluid maintenance, pressure ulcers, and [MEDICAL CONDITION] drug use. 10) Resident #18 Review of the resident's medical record, on 06/17/14 at 2:15 p.m., found a MDS with an ARD of 02/09/14. Review of the CAA summary, Section V, found the assessment had triggered the care areas of communication, activity daily living (ADL) functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, dental care, pressure ulcers, and [MEDICAL CONDITION] drug use. 11) Resident #38 Review of the resident's medical record, on 06/12/14 at 3:30 p.m., found a MDS with an ARD of 04/14/14. Review of the CAA summary, Section V, found the assessment had triggered the care areas of urinary incontinence and indwelling catheter and [MEDICAL CONDITION] drug use. 12) Resident #5 Review of the resident's medical record, on 06/12/14 at 2:00 p.m. found a MDS with an ARD of 01/10/14. Review of the CAA summary, Section V, found the assessment had triggered the care areas of visual function, ADL (activity of daily living)/rehabilitation potential, falls, pressure ulcers, and [MEDICAL CONDITION] medication use. 13) Resident #32 Review of the resident's medical record, on 06/12/14 at 2:00 p.m. found a MDS with an ARD of 05/22/14. Review of the CAA summary, Section V, found the assessment had triggered the care areas of cognitive loss/dementia, communication, behavioral symptoms, and nutritional status. 14) Resident #19 Review of the resident's medical record, on 06/12/14 at 2:00 p.m., found a MDS with an ARD of 05/16/14 . Review of the CAA summary, Section V, found the assessment had triggered the care areas of ADL (activity of daily living)/rehabilitation potential, urinary incontinence, falls, dehydration/fluid maintenance, pressure ulcers, and [MEDICAL CONDITION] drug use. 15) Resident #36 Review of the resident's medical record, on 06/12/14 at 2:00 p.m. a found MDS with an ARD of 02/22/14. Review of the CAA summary, Section V, found the assessment had triggered the care areas of. [MEDICAL CONDITION], cognitive/dementia, ADL (activity of daily living) function/rehabilitation potential, falls, pressure ulcers, and [MEDICAL CONDITION] drug use. 16) Resident #90 Review of the resident's medical record, on 06/12/14 at 2:00 p.m., found a MDS with an ARD of 04/23/14 . Review of the CAA summary, Section V, found the assessment had triggered the care areas of ADL (activity of daily living) function/rehabilitation potential, urinary incontinence, falls, dehydration/fluid maintenance, pressure ulcer, and [MEDICAL CONDITION] drug use. 17) Resident #124 Review of the resident's medical record, on 06/12/14 at 2:00 p.m. found a MDS with an ARD of 12/26/13. Review of the CAA summary, Section V, found the assessment had triggered the care areas of. cognitively loss, mood state, and behavioral symptoms. 18) Resident #83 Review of the resident's medical record, on 06/18/14 at 2:10 p.m., found a MDS with an ARD of 03/17/14. Review of the CAA summary, Section V, found the assessment had triggered the care areas of visual function, activity daily living (ADL) functional/rehabilitation potential, urinary incontinence and indwelling catheter, psychosocial well-being, falls, dehydration/fluid maintenance, dental care, pressure ulcer and [MEDICAL CONDITION] drug use. 19) Resident #76 Review of the resident's medical record on 06/18/14 at 2:05 p.m., found a MDS with an ARD of 12/31/13. Review of the CAA summary, Section V, found the assessment had triggered the care areas of ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, feeding tube, dehydration/fluid maintenance, dental care, pressure ulcer and [MEDICAL CONDITION] drug use. 20) Resident #117 Review of the resident's medical record on 06/18/14 at 2:00 p.m., found a MDS with an ARD of 05/10/14. Review of the CAA summary, Section V, found the assessment had triggered the care areas of ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, psychosocial well-being, mood state, falls, nutritional status, dehydration/fluid maintenance, and pressure ulcer. 21) Resident #225 Review of the resident's medical record on 06/17/14 at 4:45 p.m., found a MDS with an ARD of 06/09/14. Review of the CAA summary, Section V, found the assessment triggered the care areas of cognitive loss/dementia and behavioral symptoms. 22) Resident #48 Review of the resident's medical record on 06/18/14 at 2:20 p.m., found a MDS with an ARD of 05/10/14. Review of the CAA summary, Section V, found the assessment triggered the care areas of cognitive loss/dementia, visual function, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, dehydration/fluid maintenance, pressure ulcers, and [MEDICAL CONDITION] drug use. 23) Resident #3 Review of Resident #33's medical record, on 06/16/14 at 10:03 a.m., found a MDS with an ARD of 01/06/14. Review of the CAA summary, Section V, found the assessment had triggered for additional assessment the care areas of ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, dehydration/fluid maintenance, dental care, pressure ulcers, and [MEDICAL CONDITION] drug use. Review of the CAA worksheets found no documentation of the source, location and date of the information utilized to complete the additional assessment of the triggered areas. Further review of this MDS found section S3100 Contractures was not coded correctly and reflected Resident #3 had bilateral shoulder contractures, right ankle contracture, and bilateral hip contractures. Review of an Occupational Therapy screen dated 12/30/13 revealed Resident #3 did not have contractures to her shoulders, her hips or her right ankle. Additional review of the medical record found an Annual MDS with an ARD of 09/03/13. Section S3100 of this MDS was also coded inaccurately and reflected Resident #3 had a contracture to her right ankle and to her bilateral hips. The Director of Nursing (DON) was interviewed at 4:30 p.m. on 06/19/14. When asked about Resident #3's contractures, she stated Resident #3 only had contractures to her knees. She stated Resident #3 had limited range of motion to her right ankle, her shoulders and her hips, but they were not contracted. She reviewed the MDSs with ARDs of 09/13/13 and 01/06/14 and confirmed they were inaccurately coded and did not reflect Resident #3's status in regards to contractures. Observation of Resident #3 on 06/19/14 at 4:45 p.m., revealed Resident #3 had limited range of motion to her shoulders, her right ankle, and hips. Resident #3 was observed to have bilateral knee contractures. MDS/Registered Nurse (RN) #67 was interviewed at 5:00 p.m. on 06/19/14. When asked what information she reviewed to determine whether a resident had a contracture prior to coding the MDS, she replied We look at the therapy screens and code the MDS using the information on the therapy screens. Resident #3's Interdisciplinary (IDT) therapy screens, dated 06/19/13 and 09/24/13, were reviewed and neither screen indicated Resident #3 had contractures to her right ankle or bilateral hips.",2018-03-01
6502,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,273,D,0,1,3WT411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete one (1) of seven (7) admission minimum data set (MDS) assessments within fourteen (14) days of the admission. Resident identifier: #225. Facility census: 123 Findings include: a) Resident #225 A review of Resident #225's medical record on 06/17/14 at 4:45 p.m., revealed Resident #225 was admitted on [DATE]. This review found the resident's admission minimum data set (MDS) was incomplete. During an interview on 06/17/14 at 4:49 p.m., Employee #42, director of nursing (DON), and the nursing home administrator (NHA), Employee #25, were asked whether the MDS was completed in fourteen (14) days. After reviewing the resident's MDS, they stated the MDS was two (2) days past due.",2018-03-01
6503,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,278,D,0,1,3WT411,"Based on record review, observation, and staff interview, the individual completing and certifying the accuracy of information for the sections he/she completed, failed to ensure two (2) quarterly minimum data sets (MDS) accurately reflected the status for one (1) of forty-one (41) residents whose MDSs were reviewed during Stage 2 of the Quality Indicator Survey. Resident #3's status regarding contractures was not accurate. Resident Identifier: #3. Facility Census: 123 Findings Include: a) Resident #3 Review of Resident #3's medical record, at 9:42 a.m. on 06/19/14, revealed a Quarterly MDS, with an assessment reference date (ARD) of 12/01/13, was coded in accurately for contractures. Section S3100 of this MDS reflected Resident #3 had a contracture to her right ankle and to her bilateral hips. Further review of Resident #3's medical record revealed another Quarterly MDS assessment, with an ARD of 04/3/14, was also coded inaccurately and reflected Resident #3 had a contracture to her right ankle and to her bilateral hips in Section S3100. In an interview at 4:30 p.m. on 06/19/14, the Director of Nursing (DON) was asked about Resident #3's contractures. She stated the resident only had contractures to her knees and had limited range of motion to her right ankle and her hips, but they were not contracted. She reviewed the MDSs with the ARDs of 12/01/13 and 04/13/14 and confirmed they were inaccurately coded and did not reflect Resident #3's status in regards to contractures. Observation of Resident #3 on 06/19/14 at 4:45 p.m., revealed Resident #3 had limited range of motion to her shoulders, her right ankle, and hips. Only her knees were observed to have contractures. MDS/Registered Nurse (RN) #67 was interviewed at 5:00 p.m. on 06/19/14. When asked what information she reviewed to determine if a resident had a contracture prior to coding the MDS, she replied the therapy screens were reviewed and the MDS was coded using the information on the therapy screens. Resident #3's Interdisciplinary (IDT) therapy screens, dated 11/20/13 and 12/20/13 were reviewed. Neither screen indicated Resident #3 had contractures to her right ankle or bilateral hips.",2018-03-01
6504,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,279,E,0,1,3WT411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, record review, and staff interview, the facility failed to develop a comprehensive care plan, to meet the assessed needs of one (1) of forty-one (41) residents whose care plans were reviewed in Stage 2 of the Quality Indicator Survey (QIS). Resident #167's care plan did not address the resident's preference for her son to provide her showers. Resident identifier: #167. Facility Census: 123. Findings Include: a) Resident #167 During an interview with Resident #167's daughter, at 10:25 a.m. on 06/19/14, she said the resident was never showered by facility staff while at the facility. She stated her brother showered their mother because they did not feel the staff had the time or desire to provide this care to their mother. She indicated the staff were always talking about how understaffed and over worked they were, and that was why they felt it best for Resident #167's son to provide her showers. Review of Resident #167's medical record, at 11:00 a.m. on 06/19/14, found the resident was admitted to the facility on [DATE] and was discharged from the facility on 05/31/14. This review revealed a Weekly Bath and Skin Report, that indicated Resident #167 received a shower on 05/15/14, 05/20/14, and 05/24/14. There was also a progress note, dated 05/12/14, written by Registered Nurse (RN) #54. The nurse noted the resident's son was in the facility and gave the resident a shower. According to the note, RN #54 talked to the resident's son about allowing the staff to shower his mother. He had stated, Oh I am ok, I like to do it like this, I take care of Mom at home so it's no problem. Review of the resident's comprehensive care plan, with a date of 05/22/14, found it did not contain any mention of Resident #167's son showering his mother. During an interview on 06/19/14 at 6:08 p.m., RN #54 agreed Resident #167's care plan did not address the fact she preferred her son provide her showers. She stated this was true for Resident #167 from the time of admission, but it was not addressed on the comprehensive care plan.",2018-03-01
6505,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,280,D,0,1,3WT411,"Based on record review and staff interview, the facility failed to revise the care plans for one (1) of forty-one (41) residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey. The resident's care plan was not revised to accurately reflect her bathing preference or skin tears. Resident Identifier: #3. Facility Census: 123 Findings Include: a) Resident #3 1) Resident #3's medical record, reviewed at 10:03 a.m. on 06/16/14, revealed she had only received showers on 05/01/14, 04/14/14, 03/13/14, 12/16/13, 11/14/13, 11/18/13, and 11/21/14. This information was obtained from the Weekly Bath and Skin Report and the activities of daily living (ADL) records for the resident for the dates of 11/01/13 through 06/16/14. The other days, from 11/01/13 until 06/16/14, the resident received bed baths. Review of the care plan revealed a care plan intervention created on 12/07/11 with no revision dates. This intervention indicated Resident #3 preferred to take showers. The goal was: (Name) will indicate that staff has taken the necessary actions to accommodate her routines and preferences by respecting and honoring her preferences. This goal had a target date of 07/03/14. Registered Nurse (RN) #77 was interviewed on 06/18/14 at 9:56 a.m. When asked why the resident only received seven (7) showers in the previous six and a half (6-1/2) months, the RN stated she was not sure. She reviewed Resident #3's care plan, and stated the preference on her care plan was to receive showers. RN #77 said the resident should receive two (2) showers per week. The RN stated she would ask staff, who worked with the resident, why she was not receiving showers. At 10:10 a.m. on 06/18/14, RN #77 asked Licensed Practical Nurse (LPN) #75 why Resident #3 was not receiving showers. LPN #75 said Resident #3 did not like showers and would only take a bed bath. She stated the resident sometimes took a shower, but she usually had a bed bath, as it was more comfortable for her due to her knee contractures. RN #77 indicated she would revise the care plan to accurately reflect Resident #3's desire to take bed baths instead of showers. 2) Review of the resident's medical record at 10:16 a.m. on 06/19/14, revealed a care plan, initiated on 05/04/10, revised on 01/10/14, with a target date of 07/03/14: (Name) has skin tear located to her left elbow and left calf as well as a tape burn to her left arm Resident #3's skin integrity reports were reviewed. All these areas were noted as healed on 01/22/14. The resident's treatment administration record (TAR) was reviewed. It noted Resident #3 was receiving a daily treatment, beginning 05/24/14, to her right knee. RN #77 was interviewed at 3:27 p.m. on 06/19/14. When asked if Resident #3 had a skin tear to the left elbow, left calf and a tape burn to her left arm, the RN reviewed the resident's skin integrity reports. She stated those areas were healed on 01/22/14. RN #77 stated the only skin tear the resident currently had was on her right knee. When asked if Resident #3's care plan was revised to reflect the resident's current skin status, RN #77 reviewed the resident's care plan and confirmed the care plan still noted the areas which were healed on 01/22/14, and did not note the skin tear to the resident's right knee. The RN confirmed the care plan was not revised to reflect the healed areas and the skin tear to the resident's right knee.",2018-03-01
6506,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,282,D,0,1,3WT411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to implement the care plans for two (2) of forty-one (41) residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey (QIS). The care plan for Resident #55 was not implemented for thickened liquids, and a speciality cup. The care plan related to transfers for Resident #226 was not implemented. Resident Identifiers: #55 and #226. Facility Census: 123. Findings include: a) Resident #55 Observation on 06/16/14 at 12:40 p.m. revealed Resident #55 was sitting up in bed with his lunch tray sitting on the over-the-bed table. Review of the resident's meal ticket found instructions as follows: Nectar thickened liquids and sip (specialty) cup. Further observation found the resident had a small plastic drinking cup with thin consistency water and two (2) glasses (one (1) of water and one (1) of milk) of nectar thickened liquids. No specialty cups were observed on the resident's tray. On 06/16/14 at 12:45 p.m., Employee # 40, nursing assistant (NA), confirmed the resident was not to have thin liquids and should have a specialty (sip) cup for his liquids. Review of the comprehensive care plan, on 06/16/14 at 1:15 p.m., found interventions for treatment of [REDACTED]. An interview with Employee #51, licensed practical nurse (LPN), verified Resident #55 was to have nectar thickened liquids and a specialty (sip) cup. b) Resident #226 On 06/10/14 at 2:55 p.m., Resident #226 was observed being transferred from a chair to her bed by Employee #46, a nursing assistant (NA). The NA transferred the resident by standing her and pivoting her to the bed. Observation of Resident #226's room, on 06/10/14 at 3:10 p.m., found a transfer communication sheet on the resident's door. This sheet included, (Name) 2 person full lift, 450# (pound) lift, medium purple sling. Review of Resident #226's current comprehensive care plan, dated 06/01/14, revealed an intervention of, Transfers: (Name) requires assist of 2 using the Hoyer lift for all transfers. An interview with Employee #54, Unit Manager/Assistant director of nursing, and Employee #42, the director of nursing, on 06/10/14 at 3:15 p.m., confirmed Resident #226 was not transferred according to the current care plan.",2018-03-01
6507,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,309,D,0,1,3WT411,"Based on record review, staff interview, and review of the facility's protocol for standing orders, the facility failed to ensure one (1) of five (5) residents, identified during the unnecessary medication review, was provided care and services to maintain the highest practicable well-being. The physician was not notified when the resident had pain symptoms for more than twenty-four (24) hours. Resident identifier: #48. Facility census: 123. Findings include: a) Resident #48 Review of Resident #48's Medication Administration Record [REDACTED] Review of the whenever needed (PRN) pain management flow record, on 06/18/14 at 10:00 a.m., revealed on 06/12/14 the (time was not legible), the pain rating was 3-4, the location was knee. Tylenol 650 mg was given; however, the the PRN order was for fever, not pain. The same dosage of Tylenol was given again on 06/13/13. No reason was provided which described why the Tylenol was administered on 06/13/14. There was no indication the Tylenol was administered for fever. An interview was conducted on 06/18/14 at 11:00 a.m., with Employee #98 licensed practical nurse (LPN). When LPN #98 reviewed the PRN pain management flow sheet, she stated LPN #51 administered the Tylenol on 06/12/14 for knee pain. LPN #51 was interviewed on 06/19/14 at 7:50 a.m. When asked why Resident #48 was given the Tylenol on 06/12/14 and 06/13/14, she stated it was given for knee pain on both days. She said the resident had received therapy and her knee was hurting. Upon inquiry, LPN #51 said she did not notify the physician regarding the resident's knee pain, which had persisted for more than twenty-four (24) hours. On 06/19/14 at 8:00 a.m., the facility's protocol for standing orders for Tylenol for mild pain was reviewed. It directed staff to notify the physician if pain symptoms persisted for more than 24 hours.",2018-03-01
6508,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,312,D,0,1,3WT411,"Based on record review, observation, resident interview, staff interview, and a confidential interview, the facility failed to ensure two (2) of six (6) residents reviewed, who were dependent upon staff for activities of daily living (ADLs), received the assistance required to maintain good nutrition and/or personal hygiene. Resident #3 was not provided assistance with eating. Resident #27 was not provided scheduled showers. Resident identifiers: #3 and #27. Facility Census: 123. Findings Include: a) Resident #3 A confidential interview during Stage 1 of the survey, on 06/11/14 at 2:43 p.m., revealed the interviewee felt Resident #3 did not receive the assistance she needed with meals. The interviewee said Resident #3 could not see well, and sometimes did not get the food from her plate to her mouth. At times, the resident was also unable to get food onto her utensil, and would put the utensil to her mouth as if she had food on it. The interviewee indicated this was mentioned to staff, but the resident was still not provided the assistance she required. Observation of the breakfast meal on 06/19/14, in the South hall dining room, found Resident #3 received her food at 7:46 a.m. The resident was very lethargic and kept dozing off while trying to feed herself. Staff awakened the resident at 7:53 a.m., and gave her a cup of coffee. Resident #3 then dozed off again. At 7:55 a.m., the resident dropped her spoon onto her lap after she dozed off while trying to take a bite of oatmeal. At 7:58 a.m., Resident #3 was observed continuing to doze off between bites of food. At 7:59 a.m., she dropped her fork while trying to take a bite of food. The fork landed on the floor, leaving her with no utensils with which to eat her meal. At 8:00 a.m. Resident #3 was observed reaching around the edge of her bowl and her plate, as if feeling for utensils. She then dozed off again. At 8:02 a.m. the resident was again observed reaching around the edge of her plate and the edge of her bowl, as if reaching for her utensils. At 8:03 a.m. Resident #3 was observed holding her bowl of oatmeal in her left hand and was observed eating the oatmeal out of the bowl with her right hand. She dozed off again and spilled the bowl of oatmeal onto her lap. She then sat the bowl back on the table and was eating the oatmeal off her lap with her fingers. While eating the oatmeal off her lap with her fingers, she found the spoon she had dropped onto her lap earlier. She picked up the spoon and began eating the oatmeal off her lap using her spoon. At 8:07 a.m., a nurse aide (NA) was observed looking at Resident #3, but the NA offered no help or assistance. LPN #51 went to Resident #3 and stated, Here is your coffee at 8:11 a.m. At that time, Resident #3 began to drink her coffee, which was originally provided at 7:53 a.m. At 8:15 a.m., LPN #51 sat by Resident #3 and turned the resident's plate so she could reach the food on her plate. The resident dozed off and dropped a spoon of oatmeal onto her lap. She roused a bit, and with her spoon, she ate the spilled oatmeal from her lap. All the while, LPN #51 just sat and watched Resident #3. LPN #51 then asked Resident #3 if she was finished. The resident said, Yes. The LPN removed the plate from the table at 8:20 a.m. At no time was the resident provided assistance with her meal. At 8:28 a.m. on 06/19/14, Registered Nurse (RN) #77 was interviewed. She stated Resident #3 usually did very well with her meals. She then observed Resident #3 who was still sitting in the dining room and commented, She sure is a mess this morning. She then stated it did not look like the resident did very well that morning. Observation revealed the resident had oatmeal on her pants where she had spilled her bowl of food. Food was on the floor where she dropped her food instead of getting it to her mouth. The table had coffee on it where the resident spilled her coffee. RN #77 indicated she would refer Resident #3 to therapy to have her screened to see if she needed assistance with meals. LPN #51, at 8:33 a.m. on 06/19/14, stated Resident #31 seemed sleepy this morning and she usually did better than she did that morning. She continued to state to RN #77, I was sitting beside her when she dropped the one bite off her spoon. An interview with the Occupational Therapist (OT) #151, at 3:30 p.m. on 06/19/14, revealed Resident #3 would be placed on the Occupational Therapy case load. She stated she screened Resident #3 and felt she could benefit from therapy to help with positioning during meals. She indicated she would work with the resident at different meals to ensure she received the level of assistance she needed at each meal. b) Resident #27 Review of Resident #27's comprehensive care plan, on 06/19/14 at 8:00 a.m., revealed the resident required physical help with bathing. The resident was to receive two (2) showers weekly. The nursing assistant (NA) weekly shower schedule was reviewed on 06/19/14 at 8:00 a.m. According to the schedule, the resident was to be showered on Wednesdays and Saturdays on the 3-11 shift. Review of the resident's ADL records revealed the resident had no showers recorded for the month of May 2014. The resident was provided bed baths instead. An interview with the Employee #77, a unit manager/assistant director of nursing, on 06/19/14 at 8:50 a.m., confirmed the resident had no documented showers for the month of May 2014. She said he refused his showers at times, although no evidence was found to support the resident was offered and refused showers in the month of May 2014. In an interview, on 06/19/14 at 10:00 a.m., Resident #27 was asked, Do you take showers? He replied, I take showers when they give them to me. Had the resident received showers as scheduled, he would have received nine (9) showers in May 2014. The director of nursing was unable to explain why the resident did not receive showers as scheduled.",2018-03-01
6509,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,323,E,0,1,3WT411,"Based on observation and staff interview, the facility failed to provide an environment that was free from accident hazards over which the facility had control. A soiled utility closet containing chemicals and contaminated items was unlocked, medications were left out at the nurses' station unattended, a treatment cart was unlocked and unattended, a scale for weighing residents was in the middle of the dining room during a meal, and a razor was left out in a resident's bathroom. This practice had the potential to affect more than an isolated number of residents. Facility census: 123. Findings include: a) An observation, on 06/10/14 at 12:15 p.m., found the soiled utility closet was unlocked on the 300 North Hallway. The closet contained six (6) bottles of wound cleanser, a container of barrier cream cloths, a full trash can, two (2) full barrels of soiled linens, and two (2) unsanitized oxygen concentrators. Employee #51, (Licensed Practical Nurse-LPN), witnessed the door unlocked and stated staff did not always have time to lock the door to the closet. An interview with the Housekeeping Director, on 06/10/14 at 12:25 p.m., revealed the soiled utility closet was to be locked at all times. b) Observation of the transitional care unit (TCU) nursing station, on 06/16/14 at 11:25 p.m., revealed Employee #125, a registered nurse (RN), was the only nurse at the nursing station. During this observation, she left the nursing station and went down the hall. Ibuprofen (used to relieve pain and fever), Ipratroprium Bromide (used to relieve broncho spasms of the lungs), Nizatidine gelatin (used to treat ulcers in the stomach), Cephalexin (an antibiotic), mycostatin (yeast medication) were left unattended on the desk. These medications were readily accessible to residents and other persons. When Employee #125 returned to the nursing station, she was asked if she often left medication unattended on the desk. Employee #125 stated, Not normally. She then handed the medications to Employee #111, a RN, who took them to the area where they needed to go. c) Observation, on 06/16/14 at 11:45 p.m., revealed an unlocked/unattended treatment cart across from the South Hall nurses' station. This created an accident hazard, as the contents were accessible to wandering residents. The cart contained multiple tubes of ointments/medications, all of which contained directives to keep out of reach of children. The cart also contained wound cleanser, hydrogen peroxide, boxes of alcohol prep pads, and boxes of skin prep pads. When this was brought to the attention of Employee #8, a licensed practical nurse (LPN), at 12:00 a.m., the nurse locked the cart. Employee #8, an LPN, acknowledged the treatment cart should be locked at all times. d) Observation of the lunch meal, on 06/10/14, on the Transitional Care Unit (TCU), found a large scale for weighing residents in the middle of the TCU dining room. Resident #84 ambulated to the dining room using a Rollator walker, and had to maneuver around the scale to reach her table. In an interview, on 06/10/14 at 12:15 p.m., Employee #54, unit manager/assistant director of nursing, confirmed the scale created an accident hazard for Resident #84, as well as other residents. She immediately had the scale removed from the dining room. e) On 06/16/14 at 12:59 a.m., observation of Room 205, revealed a used razor stored in a cabinet in the resident's bathroom. When Employee #99, LPN, was notified of the razor being accessible to the residents, she confirmed the razor should not be in the resident's bathroom. The razor was immediately removed",2018-03-01
6510,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,356,C,0,1,3WT411,"Based on facility record review, observations, and staff interview, the facility failed to post nurse staffing data that accurately reflected the staffing numbers for the night shift, which began at 11:00 p.m. on 06/16/14 and ended at 7:00 a.m. on 06/17/14. This posting inaccurately reflected the number of nurse aides working that shift. This had the potential to affect all residents and/or visitors residing and/or visiting the facility. Facility Census: 123. Findings Includes: a) At 11:30 p.m. on 06/16/14, the Daily Nurse Staffing Form was observed posted at the North hall nurses' station. The form was completed with the name of the facility and date and reflected the total census was 125 residents. Under the section titled Night Shift (11:00 p.m. to 7:00 a.m.), the form indicated there were nine (9) nurse aides currently working on night shift at the facility. The nurse aide assignment sheets for the north, south, and the Transitional Care Unit (TCU) units were reviewed. A total of eight (8) nurse aides were identified with resident assignments for the night shift beginning at 11:00 p.m. on 06/16/14. Registered Nurse (RN) #125 was interviewed at 11:39 p.m. on 06/16/14. When asked how many nurse aides were currently working in the facility, she replied, There are eight (8) nurse aides currently working. She was then asked to review the Daily Nurse Staffing Form for accuracy. She reviewed the form and reported it was not accurate, because there were only eight (8) nurse aides working the night shift, and the form indicated there were nine (9) nurse aides working. The Director of Nursing (DON), was interviewed at 12:15 a.m. on 06/17/14. She reviewed the nursing schedule, the nurse aide assignment sheets for night shift, and the nurse staff posting. She stated it appeared someone had marked one (1) aide off the schedule, leaving only eight (8) nurse aides for the night shift. She indicated the posting was inaccurate because there were eight (8) aides working and the posting indicated there were nine (9) aides working the night shift.",2018-03-01
6511,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,364,E,0,1,3WT411,"Based on observations of meal distribution, food temperature measurements, policy review, interviews with staff, interviews with residents, review of resident council minutes, and review of customary practices for food temperatures, it was determined the facility failed to ensure foods were palatable and/or at the proper temperatures upon receipt by the residents. Residents expressed dissatisfaction with the temperature of hot foods. Foods served from the South dining room and the transitional care unit dining room were not at customary acceptable temperatures at the point of receipt by the residents. This practice had the potential to affect more than an isolated number of residents. Facility Census: 123. Findings include: a) In Stage 1 of the Quality Indicator Survey (QIS), when asked if the food at the facility was served at the proper temperature, five (5) of 25 residents interviewed answered negatively as follows: -- A lot of the time the food is cold. -- Cold at times. -- Food is cold most of the time. -- Food is cold, usually at dinner. -- It needs warmed up most of the time. b) Review of Resident council minutes, for April 22, 2014, revealed residents said French fries were cold and hard. In the same month, residents at the meeting stated meat and potatoes were cold. c) South dining room At the lunch meal on 06/10/14, observations on the south unit dining area revealed foods were not served at customary temperatures: -- Pureed Philly cheese steak sandwiches were 110 degrees F (Fahrenheit) -- Ground chopped steak was 111 degrees F -- Milk was 60 F A policy provided by Dietary Manager (DM) #102, entitled Production Tool and revised 10/06/13, directed the cook or designee to take action on unacceptable food temperatures. The food was not to be served until temperatures were correct. Cook #64 did not take this action to get the foods to an acceptable temperature at lunch on 06/10/14. An interview with Administrator #25, and DM #102, on 06/11/14 in the afternoon, revealed the foods should have been reheated in the microwave or oven, then temperatures retaken to see if the food temperatures were at acceptable levels. A policy entitled Thermometer usage, revised 04/01/14, stated the food was to be tested throughout the preparation and service to ensure the appropriate temperature was reached and maintained. It also specified that action was taken if food was not within identified ranges, prior to service. Another area in the policy included time/temperature control for safety foods reheated in a microwave for hot holding shall be reheated so that all parts of the food reached a temperature of at least 165 degrees F. d) On 06/10/14 at lunch, meal observations on the transitional care unit (TCU) dining area revealed foods were being served at improper temperatures to residents on the TCU unit who wished to eat in their rooms. Employee #102, dietary manager (DM), took the temperatures of food items on the hot well table: -- French fries were 99.5 degrees F. Employee #102, DM, made no attempt to reheat the French fries. Staff continued to serve the trays to the residents who wished to eat in their rooms. e) Hot food temperatures at the facility were too low, as determined by the residents. In addition, both hot and cold foods were not served in accordance with customary practice (as indicated in West Virginia Licensure Regulations) which is hot foods no less than 120 degrees F and cold foods no greater than 50 degrees F at the time of receipt by the resident.",2018-03-01
6512,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,371,F,0,1,3WT411,"Based on observations, measurement of food temperatures, review of facility policies, review of complaints, and staff interviews, it was determined the facility failed to store, prepare, and distribute foods under conditions which prevented, to the extent possible, the outbreak of foodborne illnesses. Foods were not held for service at proper temperatures and were not heated by methods to prevent the rapid and progressive growth of bacteria and microorganisms, foods were stored without labels and dates, undedicated wash basins were used for ice to maintain temperatures of thickened water, a freezer gasket was in disrepair, expired foods were found in the dry storage area, staff did not wear effective hair restraints, and the same gloves were used to handle non-food items, then handle food items, and residents' water pitchers were not protected from contamination. Residents #55, #109, #147, #221, #34, #33, #226, #69, #64, and #25 were specifically affected; however, these practices had the potential to affect all residents who received nourishment from the dietary department. Facility census: 123. Findings include: a) On the initial dietary tour with Dietary Manager, DM #102, on 06/10/14 at 9:40 a.m. the following issues were noted: 1. In the walk-in refrigerator a container of Dijon Mustard had an open date of 12/13 which was six (6) months ago. DM #102 agreed it would not be acceptable to use now. 2. A package of shredded cheese was open and did not have a date of opening or a label identifying the product. 3. Also in the walk-in refrigerator in the kitchen area, a container of liquid, which DM #102 identified as tomato soup or juice, was not labeled or dated to ensure staff knew what the product was and/or how long it had been opened. 4. The reach-in refrigerator in the north dining room had a carton of liquid eggs that did not have the date of when the product was opened. In addition, there was no internal thermometer in the refrigerator to ensure the unit was keeping items at the correct temperature. 5. A chest type freezer in the kitchen had the corner of the gasket torn and loose on the lid. This had the potential to impede proper sealing of the unit, resulting in items in the freezer becoming too warm. These issues were brought to the attention of DM #102 at the time of observation. b) While observing the lunch meal on 06/10/14, the following issues were observed: 1. Cook #64 was noted to reach in her pocket to retrieve packets of sanitizer wipes with a gloved hand. She then used this same gloved hand to touch food items such as the hot dog buns for the Philly cheese steak sandwiches. This created a potential for cross contamination. A policy entitled Personal hygiene, revised 10/06/13, stated disposable gloves were single use items and were to be changed between tasks. 2. Observations on the south unit dining area revealed foods were not held for service at proper temperatures: -- Pureed Philly cheese steak sandwiches were 110 degrees F (Fahrenheit) -- Ground chopped steak was 111 degrees F -- French fries were 128 degrees F -- Milk was 60 degrees F Safe food handling requires foods be held for service at temperatures which are not in the danger zone, which are temperatures between 41 degrees F and 135 degrees F. 3. During the observation of lunch on 06/10/14 in the south dining room,, observation revealed Cook #64 placed the chopped steak (which was 111 degrees F) into the well of the heatwell unit to reheat the food. Foods cannot be heated in a unit designed to hold foods, such as a steam table (heatwell unit). Foods must be heated by methods which rapidly take the food out of the danger zone. A steam table is not designed for heating. It is designed only for holding foods after they have been cooked/heated to the correct temperatures. The temperature of the chopped meat was re-taken 20 minutes after being placed in the heatwell. After 20 minutes, it had only increased 19 degrees F, to 130 degrees F, which was still in the danger zone. 4. Dietary employees were observed preparing and serving foods without effective hair restraints. Employees were observed wearing hats over their hair, but this did not effectively restrain hair which was hanging out the back of the hat. DM #102 provided a copy of the facility policy entitled Personal hygiene which stated hair restraints were to be worn and were to completely cover hair from front to back. This policy was revised with an effective date of 10/06/13. In February 2014 a customer and family concern form revealed a family member expressed concern that a long black hair was found in her mother's lunch. The follow up was for DM #102 to re-educate staff on hair restraint usage. b) On 06/10/14, water pitchers were observed on a cart in the north dining room, next to the kitchen, with no protective covering. This was again observed on the morning of 06/17/14. This practice created a potential for contamination of the water pitchers as they were exposed to residents and staff who entered and exited the dining room. On 06/18/14 at 2:30 p.m., dietary staff were observed removing the water pitchers from the clean dish area and placing them on a cart. There was no covering. Dietary Employee #9 stated they used to have a cover for the cart which went over the water pitchers, but did not know what had happened to them. At 2:25 p.m. on 06/18/14, the covers for the water pitchers was discussed with Administrator #25. She said they had some at one time, but she would have to order some or check in storage if some type of cover might already be in stock that would fit the carts and be acceptable to use. On 06/18/14 at 2:30 p.m., dietary staff were observed removing the water pitchers from the clean dish area and placing them on a cart. The water pitchers were not covered. Upon inquiry, Dietary Employee #9 stated they used to have covers for the cart which went over the water pitchers, but did not know what had happened to them. At 2:25 p.m. on 06/18/14, the covers for the water pitchers was discussed with Administrator #25. She said they had some at one time, but she would have to order some or check in storage if some type of cover might already be in stock that would fit the carts and be acceptable to use. This practice created a potential for contamination of the water pitchers as they were exposed to residents and staff who entered and exited the dining room. c) Residents #55, #109, #147, #221, #34, #33, #226, #69, #64, and #25 An initial tour of the facility on 06/10/14 at 9:30 a.m., revealed these residents had thickened water at their bedsides. It was stored in unlabeled wash basins. Some of the basins had ice and/or water in them. The basins were noted to have dirty water and some had brown stains. In an interview at 3:33 p.m. on 06/11/14, the Director of Nursing (DON) confirmed the wash basins contained ice/water for the thickened liquids. She stated the facility did not have a policy or procedure for labeling the wash basins, to make sure they were not used for anything else. She said the wash basins should be labeled to indicate they were for ice only for the thickened liquids. She confirmed, when she looked at the wash basins, they were not labeled. She said the basins should have been labeled and she would make sure they were labeled immediately. d) On 06/10/14 at lunch, meal observations on the transitional care unit (TCU) dining area were made. Foods being held for residents on the TCU unit, who wished to eat in their rooms, were being held at improper temperatures. Employee #102, dietary manager (DM), took the temperatures of food items on the hot well table: -- Pureed Philly cheese steak sandwiches were 122.5 degrees F -- French fries were 99.5 degrees F -- Milk was 47.7 degrees F e) Nutrition pantry During the initial tour of the facility, on 06/10/14 at 9:30 a.m., observation of the nutrition pantry found the following sanitation deficits in the refrigerator: -- Vanilla Haagan-Daz ice cream had an expiration date of 08/08/13. Strawberries were found with a date from the store of 02/05/14 and white grapes had a store date of 05/23/14. These items were open. They had no name or date regarding when they were placed in the refrigerator. The fruits were soft in texture. -- There was thickened dairy milk unopened in the refrigerator with an expiration date of 05/15/14. -- Several items were observed in the refrigerator which were open and had no date and/or name regarding to whom they belonged: 1. A bottle of diet coke was open with three fourth (3/4) remaining in the plastic bottle 2. A container of cantaloupe 3. Two (2) containers of watermelon 4. A plastic container of potato soup 5. Tea, punch, cranberry, and strawberry juices in plastic containers that came from the kitchen 6. A chicken combo meal from a restaurant 7. Coleslaw in a plastic container 8. Potato salad in a container with the lid half off 9. A container of thick chunky salsa In an interview on 06/10/14 at 9:30 a.m., Employee #77, assistant director of nursing (ADON), confirmed the food items were open, undated, and unlabeled in the nutrition pantry refrigerator. Employee #77 stated food in the refrigerator has a Use by date of seven (7) days. On 06/11/14 at 3:00 p.m., review of the facility's Use by dating guideline, effective 10/06/13, revealed a Use by was date 7 days after open.",2018-03-01
6513,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,412,D,0,1,3WT411,"Based on observations, review of medical records, and staff interviews, the facility failed to ensure the provision of timely dental services to meet the needs of a resident. The resident had discolored teeth, was missing a front tooth, and had red open areas on her lower gum line. This was true for one (1) of three (3) residents reviewed for the care area of dental status and services during Stage 2 of the QIS survey. Resident identifier: #69. Facility census: 123. Findings Include: a) Resident #69 During Stage 1 of the Quality Indicator Survey, on 06/10/14 at 3:49 p.m., Resident #69 was observed with a missing front tooth, and her remaining teeth were brown in color. Another observation, on 06/19/14 at 8:20 a.m., revealed the resident's lower gum line was very red and open areas were present at the gum line. Review of the dental notes, on 06/19/14 at 8:25 a.m., revealed the facility dentist noted on 02/12/14: Pt (patient) is partially edentulous u (upper) & L (lower). She has gingivitis (inflammation of the gum tissue) and periodontitis ( inflammation of the ligament and bones and bones that support the teeth). Pt needs curettage (remove tissue by scooping and scraping) and scaling : deep cleaning (removing plaque below the gum line). I can do this at the resident's bedside. On 06/19/14 at 8:45 a.m., review of the medical record found a progress note, written 02/12/14 by the assistant director of nursing (ADON), Dentist in this shift to see patient and recommends deep cleaning and scaling which can be done at bedside. Dentist to return at a later date and perform these services. POA (power of attorney) notified. In interviews, on 06/19/14 at 10:00 a.m. and at 12:00 p.m. respectively, the director of nursing (DON) and the ADON stated the facility's practice was for the dentist to come in quarterly and evaluate the residents and to provide treatment at the next visit. They both stated the facility's dentist returned on 05/14/14. They were unaware of why the resident did not receive any dental services during that visit.",2018-03-01
6514,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,441,F,0,1,3WT411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to develop, implement, and maintain an infection control program to prevent and control, to the extent possible, the development and transmission of disease and infection. Residents #55, #109, #147, #221, #34, #33, #226, #69, #64 and #25 had thickened liquids, at their bedsides, in wash basins which were not designated for that use only. Rooms #313, #222, #221, #316, #218, #317, #307, #309, #118, and #211 had soiled items and/or personal care items, which were not assigned to specific residents. Two (2) residents resided in each of these rooms. Their personal care items were co-mingled together in the rooms and/or bathrooms. In addition, residents' water pitchers were not protected from potential contamination. These practices had the potential to affect all residents residing in the facility. Facility census: 123. Findings include: a) Residents #55, #109, #147, #221, #34, #33, #226, #69, #64, and #25 During the initial tour of the facility, on 06/10/14 at 9:30 a.m., these residents had thickened water at their bedsides. The thickened liquids were in containers which were stored in unlabeled wash basins. Some of the wash basins had water and/or ice water which did not appear clean, and some of the wash basins had brown stains. There was no evidence these wash basins were used only for the thickened liquids. In an interview, at 3:33 p.m. on 06/11/14, the Director of Nursing (DON) stated there was no policy or procedure for labeling the wash basins or for a cleaning schedule to ensure the basins were routinely cleaned and sanitized. She confirmed the wash basins should be for ice only for the thickened liquids, and should be labeled as such. The DON looked at the wash basins and confirmed they were not labeled, but should have been labeled. She said she would make sure the wash basins were labeled immediately. b) Rooms #313, #222, #221, #316, #218, #317, #307, #309, #118, and #211 During the Quality Indicator Survey (QIS), infection control issues regarding co-mingling of residents' personal care items and/or unclean personal items were observed in residents' rooms. None of the personal care items were labeled or otherwise designated regarding which item belonged to which resident in any of the rooms. Two (2) residents resided in each of rooms in which infection control issues were observed: 1. room [ROOM NUMBER] An observation, on 06/11/14 at 10:20 a.m., found the privacy curtain between the residents' beds was soiled with a brown stain. Items which were not designated by resident name were noted on the bathroom sink and/or on shelves above the sink. This included three (3) bottles of shampoo, a bottle of body wash, two (2) containers of deodorant, and an emesis basin containing a denture brush and toothbrush. On the floor, under the sink, were three (3) wash basins stacked together. A disposable urine container was on the floor. A graduate (used to measure urine from a Foley catheter), with damp paper towels in it, was on the back of the commode. 2. room [ROOM NUMBER] Observation of this room, on 06/11/14 at 2:10 p.m., found the following items on the bathroom floor underneath the sink: -- a bag of trash, -- a basket of yarn -- four (4) wash basins stacked together with soiled washcloths in them On the sink were items without designation regarding which items belonged to whom: -- two (2) wash basins stacked together containing bottles of body wash, deodorant, mousse, curlers, and shampoo. Items noted on the ledge above the sink, without designation regarding which items belonged to whom, included a toothbrush, deodorant, body oil, and mouthwash A graduate, with damp paper towels in it, was on the back of the commode. 3. room [ROOM NUMBER] An observation of room [ROOM NUMBER], on 06/11/14 at 11:17 a.m., found a graduate, with damp paper towels in it, on the back of the commode. A water pitcher and glass, without designation regarding which items belonged to whom, were on the bathroom sink. A nebulizer (breathing treatment) machine was found sitting on the floor beside a resident's bed. 4. room [ROOM NUMBER] On 06/11/14 at 1:25 p.m., the following items without designation regarding which items belonged to whom, were in the bathroom on the sink and/or on shelves above the sink: -- a red cup containing a toothbrush -- shampoo -- body wash -- two (2) bottles of deodorant -- lotion Three (3) wash basins, stacked together, were on the bathroom floor under the sink. 5. room [ROOM NUMBER] On 06/11/14 at 10:52 a.m., a used bar of soap, 18 washcloths, and five (5) towels, some used and others unused, were together on the bathroom sink. 6. room [ROOM NUMBER] On 06/11/14 at 1:40 p.m., observations of the bathroom sink found these items without designation regarding which items belonged to whom: -- two (2) hairbrushes with combs sticking in them -- two (2) plastic cups sitting side by side -- one (1) container with two (2) toothbrushes, two (2) tubes of toothpaste, and one (1) tube of Fixodent. -- another cup contained a toothbrush and a used razor. Items on the ledge above the sink, without designation regarding which items belonged to whom, included mouthwash, shower gel, perineal wash, lotion, shampoo, and conditioner. 7. room [ROOM NUMBER] Observation of this room, on 06/11/14 at 10:43 a.m., found a trash can in the bathroom which contained a soiled brief. A strong odor of feces was noted throughout the bathroom and the room. 8. room [ROOM NUMBER] Observations of this room, on 06/10/14 at 3:48 p.m., found the privacy curtain between the two (2) residents' beds was soiled. A dirty wash basin was on the floor under the sink in the bathroom. 9. room [ROOM NUMBER] On 06/11/14 at 10:01 a.m., observations found a dried brown substance on the floor of the bathroom. Throughout the room, there was a strong odor of feces. 10. room [ROOM NUMBER] Observation of this room, on 06/11/14 at 10:47 a.m., found six (6) bottles of Gatorade on the floor between the beds and two (2) wash basins on the floor of the bathroom. c) An interview with the Director of Nursing, on 06/12/14 at 8:45 a.m., revealed she was aware all the rooms had infection control issues. She stated, I have directed the staff to work on the problem. In an interview with the Housekeeping Director, on 06/12/14 at 10:30 a.m., he said he was aware of the infection control issues in all the rooms. The director stated he was new and had only been able to do what he could up to this point. d) On 06/10/14, water pitchers were observed on a cart in the north dining room, next to the kitchen, with no protective covering. This was again observed on the morning of 06/17/4. This practice created a potential for contamination of the water pitchers as they were exposed to residents and staff who entered and exited the dining room. On 06/18/14 at 2:30 p.m., dietary staff were noted removing the water pitchers from the clean dish area and placing them on a cart. There was no covering. Upon inquiry, Dietary Employee #9 stated they used to have a cover for the cart which went over the water pitchers, but did not know what had happened to them. At 2:25 p.m. on 06/18/14, the covers for the water pitchers was discussed with Administrator #25. She said they had some at one time, but she would have to order some or check in storage if some type of cover might already be in stock that would fit the carts and be acceptable to use.",2018-03-01
6515,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,490,F,0,1,3WT411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, confidential interview, family interview, resident interview, policy and procedure review, and food temperature measurements, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable well-being. This practice had the potential to affect all residents. Facility census: 125. Resident Rights: The facility failed to ensure the right for prompt efforts to resolve grievances, and the right to readily accessible survey results. This practice had the potential to affect all residents. Quality of Life: The facility failed to provide effective housekeeping and maintenance services necessary to maintain an orderly, sanitary, and comfortable environment. This practice affected all residents, as sixty (60) of sixty (60) rooms had one (1) or more housekeeping and/or maintenance concerns identified during the survey. Resident Assessment: The facility failed to ensure the implementation of the State-specified Resident Assessment Instrument (RAI), which includes the minimum date set (MDS) assessment, its utilization guidelines, and the care area assessments (CAAs), to assess and address each residents' needs and strengths. This failure was identified for Residents #27, #138, #55, #226, #132, #171, #33, #11, #133, #18, #38, #5, #32, #19, #36, #90, #124, #83, #76, #117, #225, #48, #3, and #167; however, all residents had the potential to be affected. Quality of Care: The facility failed to provide an environment that was free from accident hazards over which the facility had control. This had the potential to affect more than an isolated number of residents. Dietary Services: The facility failed to store, prepare, and distribute foods under conditions which prevented, to the extent possible, the outbreak of foodborne illnesses. This failure was identified regarding the storage of thickened liquids for Residents #55, #109, #147, #221, #34, #33, #226, #69, #64, and #25; however, other failures to ensure sanitary dietary related conditions had the potential to affect all residents. Infection Control: The facility failed to develop, implement, and maintain an infection control program to prevent and control, to the extent possible, the development and transmission of disease and infection. Residents #55, #109, #147, #221, #34, #33, #226, #69, #64 and #25 and Rooms #313, #222, #221, #316, #218, #317, #307, #309, #118, and #211 were specifically identified as affected; however, these practices had the potential to affect all residents residing in the facility. These issues, which had the potential to affect all residents were identified during the survey from [DATE] through [DATE]. Facility census: 123. Findings include: a) Resident Rights Record review, review of complaints filed with the Office of Health Facility Licensure and Certification, staff interview, confidential interview, and resident interview revealed the facility failed to make efforts to promptly resolve grievances voiced by the residents: 1. On [DATE], the State Agency (OHFLAC) received a complaint alleging it took staff 30 to 45 minutes to answer resident call lights. In a confidential interview at 10:25 a.m. on [DATE], the complainant again said it took staff 30 to 45 minutes to answer residents' call lights. According to the complainant, the staff had been told about this concern, but the facility never really did anything to resolve the problem. 2. Resident #50 At 3:06 p.m. on [DATE], upon inquiry, this resident said she sometimes had to wait a long time for staff to answer her call light. She was unable to say how long it took staff to answer her call light, but stated she had to wait longer than she should have to wait. 3. Eight (8) Grievances Regarding Slow Response in Answering Call Lights -- Resident #229 On [DATE], the resident stated she had waited on the call light to be answered for 20 minutes. The action taken by the facility was to check call lights and provide education to the staff to answer the call lights quickly. Attached to the grievance was a form titled Call Light Checks, indicating call lights in four (4) random rooms were checked between the times of 10:34 a.m. and 11:00 a.m. on [DATE]. It took the staff no more than 17 minutes to answer each call light that was randomly selected. The follow-up indicated the resident was informed and was happy with the actions taken by the facility. -- Resident #231 On [DATE], this resident stated that he waited for a really long time when he turned on the call light. The action taken by the facility was to check call lights. Attached to the concern was the Call Light Checks form, indicating call lights were checked in three (3) random rooms between the times of 2:31 p.m. and 3:05 p.m. It took staff no more than five (5) minutes to answer each call light checked. The follow-up indicated the resident was informed and was happy with the actions taken by the facility. -- Resident #232 On [DATE], this resident's family stated it took too long to answer call lights. The action taken by the facility was to check call lights. Attached to the concern was the Call Light Checks form, indicating call lights were checked on [DATE] in four (4) random rooms between the times of 1:34 p.m. and 1:41 p.m. It took staff no more than one (1) minute to answer each call light checked. The follow-up indicated the resident was informed and was happy with the actions taken by the facility. -- Resident #233 On [DATE], the resident informed staff that call lights were not being answered in a timely manner. The action taken by the facility was to check call lights. Attached to the concern was the Call Light Checks form, indicating call lights were checked on [DATE] in four (4) random rooms between the times of 1:34 p.m. and 1:41 p.m. It took staff no more than one (1) minute to answer each call light checked. This was the same form which was attached to the concern from Resident #232, dated [DATE]. The follow-up indicated the resident was informed and was happy with the actions taken by the facility. -- Resident #234 On [DATE], this resident stated that call lights were not being answered timely. The action taken by the facility was to check call lights. Attached to the concern was the Call Light Checks form, indicating call lights in four (4) random rooms were checked between the times of 1:34 p.m. and 1:41 p.m. It took staff no more than one (1) minute to answer each call light checked. This was the same form which was attached to the concerns for Residents #232 and #233 on [DATE] and [DATE] respectively. The follow-up indicated the resident was informed and was happy with the actions taken by the facility. -- Resident #200 A concern dated [DATE] for Resident #200, identified the resident's concern as, Call lights. The action taken by the facility was to check call lights. Attached to the concern was a Call Light Checks form, completed on [DATE]. It indicated call lights were checked in three (3) random rooms between the times of 2:29 p.m. and 2:42 p.m. It took staff no more than two (2) minutes to answer each call light checked. The follow up indicated the call lights were activated by the person who was checking for timely answering of call lights. The form did not indicate whether the resident was informed and/or was satisfied with the facility's actions to resolve the concern. -- Resident #201 On [DATE] the resident expressed a concern of continually waiting up to 15 minutes to have the call light answered. According to the concern this resulted in the resident having episodes of incontinence. The action taken by the facility was to check call lights on evening shift. Attached to the concern was the Call Light Checks form, completed on [DATE]. It indicated call lights in four (4) random rooms were checked between the times of 1:54 p.m. and 2:36 p.m. It took staff no more than two (2) minutes to answer each call light checked. The form indicated the call lights would be checked on evening shift, but instead, were checked during day shift. -- Resident #228 On [DATE], this resident complained he waited 45 minutes on his call light. The action taken by the facility was to check call lights. There was no form attached to this concern form to indicate the call lights were checked; however, there was documentation of a follow-up with the resident and she was happy with the actions taken. -- On [DATE] at 2:36 p.m. an interview was conducted with the guest service director (GSD), the person who did the call light checks for the residents' complaints. When asked how he determined what shift to randomly pull the call lights, he stated he mostly did it on day shift around meal times unless the concern form indicated it happened on a different shift. When asked whether he spoke to the residents to identify on which shift the lights were not being answered, or to determine if it was more prevalent when specific staff were working, he stated he did not speak to the residents prior to pulling the call lights. When asked how he determined whether or not the concern was resolved, the GSD stated he just informed the resident he pulled the call lights and advised them of the response time. He said he asked them if they were happy with the resolution, and them always seemed to be satisfied with his response to these concerns. -- In an interview at 3:52 p.m. on [DATE], the Nursing Home Administrator (NHA), stated the GSD randomly pulled call lights and recorded the time to determine if it was truly taking too long to answer the call lights. Upon review of the grievances, the NHA confirmed all the call light checks were completed on day shift, and she did not see that the GSD attempted to determine on what shift or what time the residents had concerns. She stated she could start having him do a root cause analysis with the concerns to determine if it was a specific shift or when a specific staff member was working. 4. The facility failed to make the results of the most recent survey of the facility by Federal or State surveyors, and any plan of correction in effect, available for examination. The facility also failed to post a notice of the availability of the survey results in a readily accessible place. Upon initial entrance to the facility on [DATE] at 9:45 a.m., the survey results and/or notice of the location of the survey results could not be located. Employee #42, the director of nursing (DON) said the results were in a black binder located in the bookcase in the front lobby. The binder had a small white label noting Survey. When asked where the notice indicating the location of the survey results could be located, the DON found the notice was obscured in a corner of the bookcase in the front lobby. b) Quality of Life The facility failed to ensure effective housekeeping and maintenance services. The physical environment was not in good repair. The resident rooms had rusted bathroom cabinets, soiled privacy curtains, soiled floors, holes in walls, missing paint and scrapes on the walls, gloves and trash on the floors, missing cove molding, and soiled resident care equipment. 1. Rusty cabinets were found in the bathrooms of sixty of sixty resident rooms: #100, #101, #102, #103, #104, #105, #106, #107, #108, #111, #112, #113, #114, #115, #116, #117, #118, #119, #120, #121, #122, #123, #124, #200, #201, #202, #204, #205, #206, #207, #208, #209, #210, #211, #212, #213, #214, #215, #216, #217, #218, #219, #220, #221, #222, #303, #307, #309, #310, #311, #312, #313, #314, #315, #316, #317, #318, #319, #320, and #321. 2. Other maintenance concerns were identified in Rooms 101,103, 107, 110, 116, 119, 122, 213, 202, 205, 206, 209, 211, 216, 303, 307, 309, 313 and 316. These rooms and/or bathrooms had missing cove molding, cracks in the ceiling, stained ceilings, stained flooring, holes in the walls, peeling paint, scratched and/or stained bathroom doors, walls with scuff marks, privacy curtains with broken hooks, and/or door facings which were scratched. 3. Housekeeping deficits were identified during the initial tour of the facility, on [DATE] at 8:00 a.m., in Rooms 102, 104, 107, 110, 119, 124, 206, 209, 307, 309, 313, and on the Transitional Care Unit. The housekeeping concerns in the rooms included paper towels on the floor, gloves on the floor in the room and/or bathroom floor, wet wash cloths and bath towels on the bathroom floors, floors which were sticky and/or with spilled food, and/or stained privacy curtains. In addition, the floor of the wheelchair scale on the Transitional Care Unit was covered with food and soiled with a brown substance. When interviewed on [DATE] at 8:45 a.m., the director of nursing stated she was aware of the housekeeping issues and was directing the staff to do their best. In an interview on [DATE] at 10:30 a.m., the Housekeeping Director revealed he was aware of the housekeeping/maintenance issues in all rooms. The director stated he was new to the facility and was doing the best he could. d) Resident Assessment The facility failed to ensure the implementation of the State-specified Resident Assessment Instrument (RAI), which includes all required assessments and their components, the care plans, and the implementation of care plans. 1. The required documentation for the care area assessments and triggers for twenty-three (23) of forty-one (41) residents whose Minimum Data Set (MDS) assessments were reviewed were not completed. The Care Area Assessment (CAA) Summary, Section V of the MDS 3.0., nor the CAA documentation, provided the location and dates for the information used to complete the additional assessment for triggered areas. This affected the assessments for Residents #27, #138, #55, #226, #132, #171, #33, #11, #133, #18, #38, #5, #32, #19, #36, #90, #124, #83, #76, #117, #225, #48, and #3. 2. The facility failed to complete Resident #225's admission minimum data set (MDS) assessments within fourteen (14) days of the admission. The resident was admitted on [DATE]. Review of the MDS, on [DATE] at 4:45 p.m., found the MDS was incomplete. An interview was conducted, on [DATE] at 4:49 p.m., with the director of nursing and the nursing home administrator. After reviewing the resident's MDS, they confirmed the MDS was two (2) days past due. 3. Two (2) quarterly minimum data sets (MDS) did not accurately reflect the status for Resident #3. Each was certified as accurate by the individual who completed the sections related to contractures; however, the information was not accurate. Review of the medical record, at 9:42 a.m. on [DATE], revealed a Quarterly MDS, with an assessment reference date (ARD) of [DATE], was coded to reflect the resident had a contracture to her right ankle and to her bilateral hips. Another Quarterly MDS assessment, with an ARD of [DATE], was also coded to reflect the resident had a contracture to her right ankle and to her bilateral hips. An interview, at 4:30 p.m. on [DATE], with the Director of Nursing (DON), revealed the resident only had contractures to her knees. She had limited range of motion to her right ankle and her hips, but they were not contracted. She reviewed the MDSs and confirmed they were inaccurately coded regarding contractures. Observation of Resident #3, on [DATE] at 4:45 p.m., confirmed only the resident's knees were contracted. 4. The facility failed to develop a comprehensive care plan, based on the comprehensive assessment, for Resident #167. The resident's care plan did not address the resident's preference for her son to provide her showers. An interview with the resident's daughter, at 10:25 a.m. on [DATE], revealed the resident's son showered their mother while she was a resident at the facility. Review of the resident's medical record, at 11:00 a.m. on [DATE], found the resident was admitted to the facility on [DATE] and was discharged from the facility on [DATE]. The Weekly Bath and Skin Report, indicated Resident #167 received a shower on [DATE], [DATE], and [DATE]. A progress note, dated [DATE], noted the resident's son was in the facility and gave the resident a shower. According to the note, when asked about about showering his mother, the son stated, Oh I am ok, I like to do it like this, I take care of Mom at home so it's no problem. Review of the resident's comprehensive care plan, with a date of [DATE], found no mention of Resident #167's son showering his mother. An interview, on [DATE] at 6:08 p.m., with Registered Nurse #54, confirmed the resident's care plan did not address the fact she preferred her son provide her showers. 5. The facility failed to revise the care plan, when there were needed changes, for Resident #3. The resident's care plan did not accurately reflect her bathing preference for bed baths and did not reflect her current skin condition. Review of the care plan revealed a care plan intervention, originating on [DATE], which indicated Resident #3 preferred to take showers. The care plan had a target date of [DATE]. Review of the medical record revealed the resident only received showers on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The other days, from [DATE] until [DATE], the resident received bed baths. On [DATE] at 9:56 a.m. Registered Nurse (RN) #77 was asked why the resident only received seven (7) showers in the previous six (6) and a half months, when her care plan indicated she preferred showers. The RN reviewed Resident #3's care plan, and confirmed the preference on her care plan was for showers. At 10:10 a.m. on [DATE], Licensed Practical Nurse #75 said Resident #3 did not like showers and would only take a bed bath. She stated the resident sometimes took a shower, but she usually had a bed bath, as it was more comfortable for her due to her knee contractures. RN #77 confirmed the care plan did not reflect this preference for bed baths instead of showers. The resident's medical record also had a care plan, initiated on [DATE], revised on [DATE], and with a target date of [DATE] related to skin tears. It indicated the resident had a skin tear to her left elbow and left calf, as well as a tape burn to her left arm. Review of the resident's skin integrity reports revealed all these areas were noted as healed on [DATE]. Review of the resident's treatment administration record (TAR) revealed reviewed Resident #3 was receiving a daily treatment, beginning [DATE], to her right knee. This was not included on her current care plan. RN #77 was asked, at 3:27 p.m. on [DATE], if Resident #3 had a skin tear to the left elbow, left calf, and a tape burn to her left arm. The RN reviewed the resident's skin integrity reports and stated those areas were healed on [DATE]. RN #77 stated the only skin tear the resident currently had was on her right knee. At that time, RN #77 reviewed the resident's care plan and confirmed the care plan still noted the areas which were healed on [DATE], and did not note the skin tear to the resident's right knee. The RN confirmed the care plan was not revised to reflect the resident's current status related to skin integrity. 6. The facility failed to implement the care plans for Residents #55 and #226. -- Resident #55 Observation of the resident's meal ticket, on [DATE] at 12:40 p.m., revealed the resident was to have nectar thickened liquids and a sip (specialty) cup. At that time, the resident had a small plastic drinking cup with thin consistency water, a glass of nectar thickened water, and a glass of nectar thickened of milk. No specialty cups were observed on the resident's tray. On [DATE] at 12:45 p.m., Employee #40, a nursing assistant, who (NA), confirmed the resident was not to have thin liquids and should have a sip cup for his liquids. Review of the comprehensive care plan on [DATE] at 1:15 p.m., found interventions for treatment of [REDACTED]. -- Resident #226 On [DATE] at 2:55 p.m., Resident #226 was observed being transferred from a chair to her bed by Employee #46, a nursing assistant (NA). The NA transferred the resident by standing her and pivoting her to the bed. Observation, on [DATE] at 3:10 p.m., found a transfer communication sheet on the resident's door. This sheet indicated the resident required a two (2) person full lift with a 450 pound) lift and a medium purple sling. The resident's current comprehensive care plan, dated [DATE], revealed an intervention for transfers with the assist of two (2), using the Hoyer lift. An interview with the assistant director of nursing and the director of nursing, on [DATE] at 3:15 p.m., confirmed Resident #226 was not transferred according to the current care plan. e) Quality of Care The facility failed to provide an environment that was free from accident hazards over which the facility had control. A soiled utility closet containing chemicals and contaminated items was unlocked, medications were left out at the nurses' station unattended, a treatment cart was unlocked and unattended, a scale for weighing residents was in the middle of the dining room during a meal, and a razor was left out in a resident's bathroom. 1. On [DATE] at 12:15 p.m., the soiled utility closet was observed unlocked on the 300 North Hallway. The closet contained six (6) bottles of wound cleanser, a container of barrier cream cloths, a full trash can, two (2) full barrels of soiled linens, and two (2) unsanitized oxygen concentrators. 2. Observation of the transitional care unit (TCU) nursing station, on [DATE] at 11:25 p.m., revealed Registered nurse #125 walked down the hall, leaving the nursing station unattended. [MEDICATION NAME], Ipratroprium [MEDICATION NAME],, [MEDICATION NAME] gelatin, [MEDICATION NAME], and [MEDICATION NAME] were left unattended on the desk. These medications were readily accessible to residents and other persons. 3. On [DATE] at 11:45 p.m., an unlocked/unattended treatment cart was observed across from the South Hall nurses' station. This created an accident hazard, as the contents were accessible to wandering residents. The cart contained multiple tubes of medicated ointments which contained directives to keep out of reach of children. The cart also contained wound cleanser, hydrogen peroxide, boxes of alcohol prep pads, and boxes of skin prep pads. 4. Observation of the lunch meal, on [DATE], on the Transitional Care Unit (TCU), found a large scale for weighing residents in the middle of the TCU dining room. Resident #84 ambulated to the dining room using a Rollator walker, and had to maneuver around the scale to reach her table. An interview, on [DATE] at 12:15 p.m., with Employee #54, unit manager/assistant director of nursing, confirmed the scale created an accident hazard for Resident #84, as well as other residents. 5. On [DATE] at 12:59 a.m., observation of room [ROOM NUMBER] revealed a used razor stored in a cabinet in the resident's bathroom. f) Dietary Services The facility failed to store, prepare, and distribute foods under conditions which prevented, to the extent possible, the outbreak of foodborne illnesses. Foods were not held for service at proper temperatures and were not heated by methods to prevent the rapid and progressive growth of bacteria and microorganisms, foods were stored without labels and dates, undedicated wash basins were used for ice to maintain temperatures of thickened water, a freezer gasket was in disrepair, expired foods were found in the dry storage area, staff did not wear effective hair restraints, and the same gloves were used to handle non-food items, then handle food items, and residents' water pitchers were not protected from contamination. Residents #55, #109, #147, #221, #34, #33, #226, #69, #64, and #25 were specifically affected; however, these practices had the potential to affect all residents who received nourishment from the dietary department. 1. On the initial dietary tour with Dietary Manager, DM #102, on [DATE] at 9:40 a.m. the following issues were found under refrigeration: a container of Dijon Mustard opened ,[DATE], an open unlabeled and undated package of shredded cheese, a container of red liquid which was not labeled or dated, and a carton of liquid eggs with no date indicating when it was opened. In addition, there was no internal thermometer in the refrigerator to ensure the unit was keeping items at the correct temperature. 2. A chest type freezer in the kitchen had the corner of the gasket torn and loose on the lid. This had the potential to impede proper sealing and temperature control of the of the unit. 3. During observation of the lunch meal on [DATE], Cook #64 reached into her pocket with a gloved hand, to retrieve . She then used this now contaminated glove to touch hot dog buns. This created a potential for cross contamination. 4. Observations on the south unit dining area revealed foods were not held for service at proper temperatures. Pureed Philly cheese steak sandwiches were 110 degrees F (Fahrenheit), ground chopped steak was 111 degrees F, French fries were 128 degrees F, and milk was 60 degrees F. Safe food handling requires foods be held for service at temperatures which are not in the danger zone, which are temperatures between 41 degrees F and 135 degrees F. 5. Observation of lunch on [DATE] in the south dining room, revealed Cook #64 placed the chopped steak (which was 111 degrees F) into the well of the heatwell unit to reheat the food. Foods cannot be heated in a unit designed to hold foods. They must be heated by methods which rapidly take the food out of the danger zone. A steam table is not designed for heating. It is designed only for holding foods after they have been cooked/heated to the correct temperatures. The temperature of the chopped meat was re-taken 20 minutes after being placed in the heatwell. After 20 minutes, it had only increased 19 degrees F, to 130 degrees F, which was still in the danger zone. 6. Dietary employees were observed preparing and serving foods without effective hair restraints. They wore hats over their hair, but this did not effectively restrain hair which was hanging out the back of the hat. The facility policy entitled Personal hygiene, with an effective date of [DATE], indicated hair restraints were to completely cover hair from front to back. 7. On [DATE], water pitchers were observed on a cart in the north dining room, next to the kitchen, with no protective covering. This was again observed on the morning of [DATE]. This practice created a potential for contamination of the water pitchers as they were exposed to residents and staff who entered and exited the dining room. On [DATE] at 2:30 p.m., dietary staff were observed removing the water pitchers from the clean dish area and placing them on a cart. There was no covering. Dietary Employee #9 stated they used to have a cover for the cart which went over the water pitchers, but did not know what had happened to them. g) Infection Control The facility failed to develop, implement, and maintain an infection control program to prevent and control, to the extent possible, the development and transmission of disease and infection. Residents #55, #109, #147, #221, #34, #33, #226, #69, #64 and #25 had thickened liquids, at their bedsides, in wash basins which were not designated for that use only. Rooms #313, #222, #221, #316, #218, #317, #307, #309, #118, and #211 had soiled items and/or personal care items, which were not assigned to specific residents. Two (2) residents resided in each of these rooms. Their personal care items were co-mingled together in the rooms and/or bathrooms. In addition, residents' water pitchers were not protected from potential contamination. 1. Residents #55, #109, #147, #221, #34, #33, #226, #69, #64, and #25 On [DATE] at 9:30 a.m., these residents had thickened water at their bedsides. The thickened liquids were in containers which were stored in unlabeled wash basins. Some of the wash basins had water and/or ice water which did not appear clean, and some of the wash basins had brown stains. There was no evidence these wash basins were used only for the thickened liquids. In an interview, at 3:33 p.m. on [DATE], the Director of Nursing (DON) stated there was no policy or procedure for labeling the wash basins or for a cleaning schedule to ensure the basins were routinely cleaned and sanitized. She confirmed the wash basins should be for ice only for the thickened liquids, and should be labeled as such. The DON looked at the wash basins and confirmed they were not labeled, but should have been labeled. 2) Rooms #313, #222, #221, #316, #218, #317, #307, #309, #118, and #211 Infection control issues regarding co-mingling of residents' personal care items and/or unclean personal and shared items were observed in residents' rooms. None of the personal care items were labeled or otherwise designated regarding which item belonged to which resident in any of the rooms. Two (2) residents resided in each of rooms in which infection control issues were observed: -- room [ROOM NUMBER] Observation, on [DATE] at 10:20 a.m., found the privacy curtain between the residents' beds was soiled with a brown stain. Items which were not designated by resident name were noted on the bathroom sink and/or on shelves above the sink. This included three (3) bottles of shampoo, a bottle of body wash, two (2) containers of deodorant, and an emesis basin containing a denture brush and toothbrush. On the floor, under the sink, were three (3) wash basins stacked together. A disposable urine container was on the floor. A graduate (used to measure urine from a Foley catheter), with damp paper towels in it, was on the back of the commode. -- room [ROOM NUMBER] Observation of this room, on [DATE] at 2:10 p.m., found a bag of trash, a basket of yarn, and four (4) wash basins stacked together with soiled washcloths in them on the bathroom floor underneath the sink. Also, two (2) wash basins stacked together containing bottles of body wash, deodorant, mousse, curlers, and shampoo were on the sink. There was no designation regarding which items belonged to whom. Items on the ledge above the sink, without designation regarding which items belonged to whom, included a toothbrush, deodorant, body oil, and mouthwash. A graduate, with paper towels in it, was on the back of the commode. -- room [ROOM NUMBER] An observation of room [ROOM NUMBER], on [DATE] at 11:17 a.m., found a graduate, with paper towels in it, on the back of the commode. A water pitcher and glass, without designation regarding which items belonged to whom, were on the bathroom sink. A nebulizer (breathing treatment) machine was found sitting on the floor beside a resident's bed. -- room [ROOM NUMBER] On [DATE] at 1:25 p.m., a red cup containing a toothbrush, shampoo, body wash, two (2) bottles of deodorant, and lotion, without designation regarding which items belonged to whom, were in the bathroom on the sink and/or on shelves above the sink. Also, three (3) wash basins, stacked together, were on the bathroom floor under the sink. -- room [ROOM NUMBER] On [DATE] at 10:52 a.m., a used bar of soap, 18 washcloths, and five (5) towels, some used and others unused, were together on the bathroom sink. -- room [ROOM NUMBER] On [DATE] at 1:40 p.m., two (2) hairbrushes with combs stic (TRUNCATED)",2018-03-01
6516,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,492,D,0,1,3WT411,"Based on record review and staff interview, the facility failed to ensure compliance with West Virginia State laws and regulations. One (1) of ten (10) employees, whose personnel files were reviewed, was not informed about the Central Abuse Registry as required by West Virginia code 15-2c-8, and about the nurse aide abuse registry, as required by West Virginia code 69-6-8. Employee Identifier: #94. Facility Census: 123. Findings Include: a) Nurse Aide #94 On 06/17/14 at 1:00 p.m., review of Nurse Aide (NA) #94's personnel file revealed the file did not contain a Central Abuse Registry notice as required by West Virginia Code 15-2c-8. West Virginia Code 15-2c-8 includes, ?15-2C-8 Service provider responsibilities. All residential care facilities, day care centers, providers to adults with behavioral health needs and home care service providers authorized to operate in West Virginia must provide notice to employees at the time of employment of the central abuse registry. Nurse Aide #94's personnel file also did not contain a notice of the Nurse Aide Abuse Registry as required by West Virginia Code 69-6-8, which requires each facility to provide a copy of the rule to each Nurse Aide at the time of hiring, and to keep signed proof that each Nurse Aide received a copy of the rule. In an interview with the Nursing Home Administrator, at 2:05 p.m. on 06/18/14, she confirmed Employee #94's personnel record did not contain the Central Abuse Registry and the Nurse Aide Abuse Registry notices.",2018-03-01
6517,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,514,E,0,1,3WT411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain an accurate and complete medical record for all residents. This was true for fifteen (15) of thirty-six (36) medical records reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #216's medical record did not contain a copy of her Medical Power of Attorney (MPOA). Residents #8, #3, #45, #54, #169, #12, #88, #125, #116, and #69 had documentation on the Nurse Aide flow sheets for a date in the future. Resident #19's medical record contained a progress note that belonged in the medical record of her roommate. Residents #5 and #36 had incomplete documentation regarding the amount of snacks they consumed. Resident #76 had documentation in her medical record indicating she was incontinent of bladder; however, she had an indwelling catheter. Resident Identifiers: #216, #8, #3, #45, #54, #169, #12, #88, #125, #116, #69, #19, #5, #36, and #76. Facility Census: 123. Findings Include: a) Resident #216 Review of Resident #216's medical record, at 1:00 p.m. on 06/18/14, revealed a Physician Determination of Capacity dated 04/27/14. It identified the resident did not have capacity to make medical decisions. In an interview, at 1:34 p.m. on 06/18/14, Social Worker #62, was asked who Resident #216's healthcare decision maker was. She replied, It is her nephew, he is her MPOA. When asked to locate the MPOA form in Resident #216's medical record, she looked through the medical record and said the form was not in the resident's medical record. She stated she would have to look for it to see what had happened to it. Social Worker #62 was again interviewed at 4:30 p.m. on 06/18/14. She provided a copy of Resident #216's MPOA form. When asked where the form was located, she stated, I had her nephew bring in another copy, because it must have got sent out with the resident and was never returned to the facility. b) Residents #8, #3, #45, #54, #169, #12, #88, #125, #116, and #69 At 11:30 p.m. on 06/16/14, review of Activity of Daily Living (ADL) records revealed Residents #8, #3, #45, #54, #169, #12, #88, #125, #116 and #69 had documentation on their ADL records for 06/17/14 for the 7:00 a.m. to 3:00 p.m. shift and for the 3:00 p.m. to 11:00 p.m. shift. At the time of the review, those were future shifts which should not have already been documented. In an interview at 12:15 a.m. on 06/17/14, the Director of Nursing (DON) was asked to review the ADL records for Residents #8, #3, #45, #54, #169, #12, #88, #125, #116, and #69. She reviewed the ADL records and confirmed NA #56 documented the provision of ADLs, on 06/17/14, for the 7:00 a.m. to 3:00 p.m. shift and for the 3:00 p.m. to 11:00 p.m. shifts for ADLs which had not yet occurred. c) Resident #19 A review of this resident's medical record on 06/12/14 revealed a nursing note in the resident's record which belonged in Resident #167's medical record. The note was dated 05/12/14 at 10:46 a.m. This was verified with DON, at 9:30 a.m. on 06/12/14. She said the note was concerning an issue which occurred with a family member of the resident's roommate, and was entered in the wrong medical record. d) Resident #5 A review of the medical record for this resident revealed incomplete documentation of the amount of the snack consumed by the resident. The ADL record form for May 2014 was provided by the DON on 06/12/14. Documentation for the month of May 2014 showed no amount of the snack the resident consumed for May 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 15, 19, 21, 22, 23, 25, and 31. e) Resident #36 On 06/12/14, the DON provided the ADL record for the month of June. The form showed there were no amounts of snacks consumed documented on June 3, 7, 8, and 10. f) Documentation of snack consumption was discussed with the DON on 06/16/14 in the afternoon. She confirmed the consumption of snacks on the flow sheets was incomplete for Residents #5 and #36. g) Resident #76 On 06/12/14 at 2:30 p.m., record review found a nursing entry dated 01/11/14 by Registered Nurse (RN) #78. It noted Resident #76 was incontinent of bowel and bladder (B&B). A review of the physician's orders [REDACTED].#76 had a Foley catheter due to [MEDICAL CONDITION]. In an interview with the DON, on 06/12/14 at 2:42 p.m., she was asked about the nurse's note in which Employee #78 documented the resident was incontinent of B&B. The DON stated, That cannot be right because the resident has a Foley catheter. She confirmed the nurse incorrectly documented in the resident's medical record.",2018-03-01
6518,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,520,F,0,1,3WT411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observation, staff interviews, confidential interview, family interview, resident interviews, policy and procedure review, and food temperature measurements, the quality assessment and assurance committee (QA & A) failed to identify and act upon quality deficiencies in the daily operation of the facility of which it did have, or should have had knowledge. Resident Rights: The QA & A committee failed to identify and act upon the facility's failure to ensure the right for prompt efforts to resolve grievances, and the right to readily accessible survey results. This practice had the potential to affect all residents. Quality Of Life: The QA & A committee failed to identify and act upon the facility's failure to ensure the provision of effective housekeeping and maintenance services necessary to maintain an orderly, sanitary, and comfortable environment. This practice affected all residents, as sixty (60) of sixty (60) rooms had one (1) or more housekeeping and/or maintenance concerns identified during the survey. Resident Assessment: The QA & A committee failed to identify and act upon the facility's failure to ensure the implementation of the State-specified Resident Assessment Instrument (RAI), which includes the minimum date set (MDS) assessment, its utilization guidelines, and the care area assessments (CAAs), to assess and address each residents' needs and strengths. This failure was identified for Residents #27, #138, #55, #226, #132, #171, #33, #11, #133, #18, #38, #5, #32, #19, #36, #90, #124, #83, #76, #117, #225, #48, #3, and #167; however, all residents had the potential to be affected. Quality of Care: The QA & A committee failed to identify and act upon the facility's failure to ensure the provision of an environment that was free from accident hazards over which the facility had control. This had the potential to affect more than an isolated number of residents. Dietary Services: The QA & A committee failed to identify and act upon the facility's failure to ensure foods were stored, prepared, and distributed under conditions which prevented, to the extent possible, the outbreak of foodborne illnesses. This failure was identified regarding the storage of thickened liquids for Residents #55, #109, #147, #221, #34, #33, #226, #69, #64, and #25; however, other failures to ensure sanitary dietary related conditions had the potential to affect all residents. Infection Control: The QA & A committee failed to identify and act upon the facility's failure to develop, implement, and maintain an infection control program to prevent and control, to the extent possible, the development and transmission of disease and infection. Residents #55, #109, #147, #221, #34, #33, #226, #69, #64 and #25 and Rooms #313, #222, #221, #316, #218, #317, #307, #309, #118, and #211 were specifically identified as affected; however, these practices had the potential to affect all residents residing in the facility. These issues, which had the potential to affect all residents were identified during the survey from [DATE] through [DATE]. Facility census: 123. Findings include: a) Resident Rights Record review, review of complaints filed with the Office of Health Facility Licensure and Certification, staff interview, confidential interview, and resident interview revealed the facility failed to make efforts to promptly resolve grievances voiced by the residents: 1. On [DATE], the State Agency (OHFLAC) received a complaint alleging it took staff 30 to 45 minutes to answer resident call lights. In a confidential interview at 10:25 a.m. on [DATE], the complainant again said it took staff 30 to 45 minutes to answer residents' call lights. According to the complainant, the staff had been told about this concern, but the facility never really did anything to resolve the problem. 2. Resident #50 At 3:06 p.m. on [DATE], upon inquiry, this resident said she sometimes had to wait a long time for staff to answer her call light. She was unable to say how long it took staff to answer her call light, but stated she had to wait longer than she should have to wait. 3. Eight (8) Grievances Regarding Slow Response in Answering Call Lights -- Resident #229 On [DATE], the resident stated she had waited on the call light to be answered for 20 minutes. The action taken by the facility was to check call lights and provide education to the staff to answer the call lights quickly. Attached to the grievance was a form titled Call Light Checks, indicating call lights in four (4) random rooms were checked between the times of 10:34 a.m. and 11:00 a.m. on [DATE]. It took the staff no more than 17 minutes to answer each call light that was randomly selected. The follow-up indicated the resident was informed and was happy with the actions taken by the facility. -- Resident #231 On [DATE], this resident stated that he waited for a really long time when he turned on the call light. The action taken by the facility was to check call lights. Attached to the concern was the Call Light Checks form, indicating call lights were checked in three (3) random rooms between the times of 2:31 p.m. and 3:05 p.m. It took staff no more than five (5) minutes to answer each call light checked. The follow-up indicated the resident was informed and was happy with the actions taken by the facility. -- Resident #232 On [DATE], this resident's family stated it took too long to answer call lights. The action taken by the facility was to check call lights. Attached to the concern was the Call Light Checks form, indicating call lights were checked on [DATE] in four (4) random rooms between the times of 1:34 p.m. and 1:41 p.m. It took staff no more than one (1) minute to answer each call light checked. The follow-up indicated the resident was informed and was happy with the actions taken by the facility. -- Resident #233 On [DATE], the resident informed staff that call lights were not being answered in a timely manner. The action taken by the facility was to check call lights. Attached to the concern was the Call Light Checks form, indicating call lights were checked on [DATE] in four (4) random rooms between the times of 1:34 p.m. and 1:41 p.m. It took staff no more than one (1) minute to answer each call light checked. This was the same form which was attached to the concern from Resident #232, dated [DATE]. The follow-up indicated the resident was informed and was happy with the actions taken by the facility. -- Resident #234 On [DATE], this resident stated that call lights were not being answered timely. The action taken by the facility was to check call lights. Attached to the concern was the Call Light Checks form, indicating call lights in four (4) random rooms were checked between the times of 1:34 p.m. and 1:41 p.m. It took staff no more than one (1) minute to answer each call light checked. This was the same form which was attached to the concerns for Residents #232 and #233 on [DATE] and [DATE] respectively. The follow-up indicated the resident was informed and was happy with the actions taken by the facility. -- Resident #200 A concern dated [DATE] for Resident #200, identified the resident's concern as, Call lights. The action taken by the facility was to check call lights. Attached to the concern was a Call Light Checks form, completed on [DATE]. It indicated call lights were checked in three (3) random rooms between the times of 2:29 p.m. and 2:42 p.m. It took staff no more than two (2) minutes to answer each call light checked. The follow up indicated the call lights were activated by the person who was checking for timely answering of call lights. The form did not indicate whether the resident was informed and/or was satisfied with the facility's actions to resolve the concern. -- Resident #201 On [DATE] the resident expressed a concern of continually waiting up to 15 minutes to have the call light answered. According to the concern this resulted in the resident having episodes of incontinence. The action taken by the facility was to check call lights on evening shift. Attached to the concern was the Call Light Checks form, completed on [DATE]. It indicated call lights in four (4) random rooms were checked between the times of 1:54 p.m. and 2:36 p.m. It took staff no more than two (2) minutes to answer each call light checked. The form indicated the call lights would be checked on evening shift, but instead, were checked during day shift. -- Resident #228 On [DATE], this resident complained he waited 45 minutes on his call light. The action taken by the facility was to check call lights. There was no form attached to this concern form to indicate the call lights were checked; however, there was documentation of a follow-up with the resident and she was happy with the actions taken. -- On [DATE] at 2:36 p.m. an interview was conducted with the guest service director (SD), the person who did the call light checks for the residents' complaints. When asked how he determined what shift to randomly pull the call lights, he stated he mostly did it on day shift around meal times unless the concern form indicated it happened on a different shift. When asked whether he spoke to the residents to identify on which shift the lights were not being answered, or to determine if it was more prevalent when specific staff were working, he stated he did not speak to the residents prior to pulling the call lights. When asked how he determined whether or not the concern was resolved, the SD stated he just informed the resident he pulled the call lights and advised them of the response time. He said he asked them if they were happy with the resolution, and them always seemed to be satisfied with his response to these concerns. -- In an interview at 3:52 p.m. on [DATE], the Nursing Home Administrator (NHA), stated the SD randomly pulled call lights and recorded the time to determine if it was truly taking too long to answer the call lights. Upon review of the grievances, the NHA confirmed all the call light checks were completed on day shift, and she did not see that the GSD attempted to determine on what shift or what time the residents had concerns. She stated she could start having him do a root cause analysis with the concerns to determine if it was a specific shift or when a specific staff member was working. 4. The facility failed to make the results of the most recent survey of the facility by Federal or State surveyors, and any plan of correction in effect, available for examination. The facility also failed to post a notice of the availability of the survey results in a readily accessible place. Upon initial entrance to the facility on [DATE] at 9:45 a.m., the survey results and/or notice of the location of the survey results could not be located. Employee #42, the director of nursing (DON) said the results were in a black binder located in the bookcase in the front lobby. The binder had a small white label noting Survey. When asked where the notice indicating the location of the survey results could be located, the DON found the notice was obscured in a corner of the bookcase in the front lobby. b) Quality of Life The facility failed to ensure effective housekeeping and maintenance services. The physical environment was not in good repair. The resident rooms had rusted bathroom cabinets, soiled privacy curtains, soiled floors, holes in walls, missing paint and scrapes on the walls, gloves and trash on the floors, missing cove molding, and soiled resident care equipment. 1. Rusty cabinets were found in the bathrooms of sixty of sixty resident rooms: #100, #101, #102, #103, #104, #105, #106, #107, #108, #111, #112, #113, #114, #115, #116, #117, #118, #119, #120, #121, #122, #123, #124, #200, #201, #202, #204, #205, #206, #207, #208, #209, #210, #211, #212, #213, #214, #215, #216, #217, #218, #219, #220, #221, #222, #303, #307, #309, #310, #311, #312, #313, #314, #315, #316, #317, #318, #319, #320, and #321. 2. Other maintenance concerns were identified in Rooms 101,103, 107, 110, 116, 119, 122, 213, 202, 205, 206, 209, 211, 216, 303, 307, 309, 313 and 316. These rooms and/or bathrooms had missing cove molding, cracks in the ceiling, stained ceilings, stained flooring, holes in the walls, peeling paint, scratched and/or stained bathroom doors, walls with scuff marks, privacy curtains with broken hooks, and/or door facings which were scratched. 3. Housekeeping deficits were identified during the initial tour of the facility, on [DATE] at 8:00 a.m., in Rooms 102, 104, 107, 110, 119, 124, 206, 209, 307, 309, 313, and on the Transitional Care Unit. The housekeeping concerns in the rooms included paper towels on the floor, gloves on the floor in the room and/or bathroom floor, wet wash cloths and bath towels on the bathroom floors, floors which were sticky and/or with spilled food, and/or stained privacy curtains. In addition, the floor of the wheelchair scale on the Transitional Care Unit was covered with food and soiled with a brown substance. When interviewed on [DATE] at 8:45 a.m., the director of nursing stated she was aware of the housekeeping issues and was directing the staff to do their best. In an interview on [DATE] at 10:30 a.m., the Housekeeping Director revealed he was aware of the housekeeping/maintenance issues in all rooms. The director stated he was new to the facility and was doing the best he could. d) Resident Assessment The facility failed to ensure the implementation of the State-specified Resident Assessment Instrument (RAI), which includes all required assessments and their components, the care plans, and the implementation of care plans. 1. The required documentation for the care area assessments and triggers for twenty-three (23) of forty-one (41) residents whose Minimum Data Set (MDS) assessments were reviewed were not completed. The Care Area Assessment (CAA) Summary, Section V of the MDS 3.0., nor the CAA documentation, provided the location and dates for the information used to complete the additional assessment for triggered areas. This affected the assessments for Residents #27, #138, #55, #226, #132, #171, #33, #11, #133, #18, #38, #5, #32, #19, #36, #90, #124, #83, #76, #117, #225, #48, and #3. 2. The facility failed to complete Resident #225's admission minimum data set (MDS) assessments within fourteen (14) days of the admission. The resident was admitted on [DATE]. Review of the MDS, on [DATE] at 4:45 p.m., found the MDS was incomplete. An interview was conducted, on [DATE] at 4:49 p.m., with the director of nursing and the nursing home administrator. After reviewing the resident's MDS, they confirmed the MDS was two (2) days past due. 3. Two (2) quarterly minimum data sets (MDS) did not accurately reflect the status for Resident #3. Each was certified as accurate by the individual who completed the sections related to contractures; however, the information was not accurate. Review of the medical record, at 9:42 a.m. on [DATE], revealed a Quarterly MDS, with an assessment reference date (ARD) of [DATE], was coded to reflect the resident had a contracture to her right ankle and to her bilateral hips. Another Quarterly MDS assessment, with an ARD of [DATE], was also coded to reflect the resident had a contracture to her right ankle and to her bilateral hips. An interview, at 4:30 p.m. on [DATE], with the Director of Nursing (DON), revealed the resident only had contractures to her knees. She had limited range of motion to her right ankle and her hips, but they were not contracted. She reviewed the MDSs and confirmed they were inaccurately coded regarding contractures. Observation of Resident #3, on [DATE] at 4:45 p.m., confirmed only the resident's knees were contracted. 4. The facility failed to develop a comprehensive care plan, based on the comprehensive assessment, for Resident #167. The resident's care plan did not address the resident's preference for her son to provide her showers. An interview with the resident's daughter, at 10:25 a.m. on [DATE], revealed the resident's son showered their mother while she was a resident at the facility. Review of the resident's medical record, at 11:00 a.m. on [DATE], found the resident was admitted to the facility on [DATE] and was discharged from the facility on [DATE]. The Weekly Bath and Skin Report, indicated Resident #167 received a shower on [DATE], [DATE], and [DATE]. A progress note, dated [DATE], noted the resident's son was in the facility and gave the resident a shower. According to the note, when asked about about showering his mother, the son stated, Oh I am ok, I like to do it like this, I take care of Mom at home so it's no problem. Review of the resident's comprehensive care plan, with a date of [DATE], found no mention of Resident #167's son showering his mother. An interview, on [DATE] at 6:08 p.m., with Registered Nurse #54, confirmed the resident's care plan did not address the fact she preferred her son provide her showers. 5. The facility failed to revise the care plan, when there were needed changes, for Resident #3. The resident's care plan did not accurately reflect her bathing preference for bed baths and did not reflect her current skin condition. Review of the care plan revealed a care plan intervention, originating on [DATE], which indicated Resident #3 preferred to take showers. The care plan had a target date of [DATE]. Review of the medical record revealed the resident only received showers on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The other days, from [DATE] until [DATE], the resident received bed baths. On [DATE] at 9:56 a.m. Registered Nurse (RN) #77 was asked why the resident only received seven (7) showers in the previous six (6) and a half months, when her care plan indicated she preferred showers. The RN reviewed Resident #3's care plan, and confirmed the preference on her care plan was for showers. At 10:10 a.m. on [DATE], Licensed Practical Nurse #75 said Resident #3 did not like showers and would only take a bed bath. She stated the resident sometimes took a shower, but she usually had a bed bath, as it was more comfortable for her due to her knee contractures. RN #77 confirmed the care plan did not reflect this preference for bed baths instead of showers. The resident's medical record also had a care plan, initiated on [DATE], revised on [DATE], and with a target date of [DATE] related to skin tears. It indicated the resident had a skin tear to her left elbow and left calf, as well as a tape burn to her left arm. Review of the resident's skin integrity reports revealed all these areas were noted as healed on [DATE]. Review of the resident's treatment administration record (TAR) revealed reviewed Resident #3 was receiving a daily treatment, beginning [DATE], to her right knee. This was not included on her current care plan. RN #77 was asked, at 3:27 p.m. on [DATE], if Resident #3 had a skin tear to the left elbow, left calf, and a tape burn to her left arm. The RN reviewed the resident's skin integrity reports and stated those areas were healed on [DATE]. RN #77 stated the only skin tear the resident currently had was on her right knee. At that time, RN #77 reviewed the resident's care plan and confirmed the care plan still noted the areas which were healed on [DATE], and did not note the skin tear to the resident's right knee. The RN confirmed the care plan was not revised to reflect the resident's current status related to skin integrity. 6. The facility failed to implement the care plans for Residents #55 and #226. -- Resident #55 Observation of the resident's meal ticket, on [DATE] at 12:40 p.m., revealed the resident was to have nectar thickened liquids and a sip (specialty) cup. At that time, the resident had a small plastic drinking cup with thin consistency water, a glass of nectar thickened water, and a glass of nectar thickened of milk. No specialty cups were observed on the resident's tray. On [DATE] at 12:45 p.m., Employee #40, a nursing assistant, who (NA), confirmed the resident was not to have thin liquids and should have a sip cup for his liquids. Review of the comprehensive care plan on [DATE] at 1:15 p.m., found interventions for treatment of [REDACTED]. -- Resident #226 On [DATE] at 2:55 p.m., Resident #226 was observed being transferred from a chair to her bed by Employee #46, a nursing assistant (NA). The NA transferred the resident by standing her and pivoting her to the bed. Observation, on [DATE] at 3:10 p.m., found a transfer communication sheet on the resident's door. This sheet indicated the resident required a two (2) person full lift with a 450 pound) lift and a medium purple sling. The resident's current comprehensive care plan, dated [DATE], revealed an intervention for transfers with the assist of two (2), using the Hoyer lift. An interview with the assistant director of nursing and the director of nursing, on [DATE] at 3:15 p.m., confirmed Resident #226 was not transferred according to the current care plan. e) Quality of Care The facility failed to provide an environment that was free from accident hazards over which the facility had control. A soiled utility closet containing chemicals and contaminated items was unlocked, medications were left out at the nurses' station unattended, a treatment cart was unlocked and unattended, a scale for weighing residents was in the middle of the dining room during a meal, and a razor was left out in a resident's bathroom. 1. On [DATE] at 12:15 p.m., the soiled utility closet was observed unlocked on the 300 North Hallway. The closet contained six (6) bottles of wound cleanser, a container of barrier cream cloths, a full trash can, two (2) full barrels of soiled linens, and two (2) insanities oxygen concentrators. 2. Observation of the transitional care unit (CU) nursing station, on [DATE] at 11:25 p.m., revealed Registered nurse #125 walked down the hall, leaving the nursing station unattended. [MEDICATION NAME], Ipratroprium [MEDICATION NAME],, [MEDICATION NAME] gelatin, [MEDICATION NAME], and [MEDICATION NAME] were left unattended on the desk. These medications were readily accessible to residents and other persons. 3. On [DATE] at 11:45 p.m., an unlocked/unattended treatment cart was observed across from the South Hall nurses' station. This created an accident hazard, as the contents were accessible to wandering residents. The cart contained multiple tubes of medicated ointments which contained directives to keep out of reach of children. The cart also contained wound cleanser, hydrogen peroxide, boxes of alcohol prep pads, and boxes of skin prep pads. 4. Observation of the lunch meal, on [DATE], on the Transitional Care Unit (TCU), found a large scale for weighing residents in the middle of the TCU dining room. Resident #84 ambulated to the dining room using a Rollator walker, and had to maneuver around the scale to reach her table. An interview, on [DATE] at 12:15 p.m., with Employee #54, unit manager/assistant director of nursing, confirmed the scale created an accident hazard for Resident #84, as well as other residents. 5. On [DATE] at 12:59 a.m., observation of room [ROOM NUMBER] revealed a used razor stored in a cabinet in the resident's bathroom. f) Dietary Services The facility failed to store, prepare, and distribute foods under conditions which prevented, to the extent possible, the outbreak of foodborne illnesses. Foods were not held for service at proper temperatures and were not heated by methods to prevent the rapid and progressive growth of bacteria and microorganisms, foods were stored without labels and dates, undedicated wash basins were used for ice to maintain temperatures of thickened water, a freezer gasket was in disrepair, expired foods were found in the dry storage area, staff did not wear effective hair restraints, and the same gloves were used to handle non-food items, then handle food items, and residents' water pitchers were not protected from contamination. Residents #55, #109, #147, #221, #34, #33, #226, #69, #64, and #25 were specifically affected; however, these practices had the potential to affect all residents who received nourishment from the dietary department. 1. On the initial dietary tour with Dietary Manager, DM #102, on [DATE] at 9:40 a.m. the following issues were found under refrigeration: a container of Dijon Mustard opened ,[DATE], an open unlabeled and undated package of shredded cheese, a container of red liquid which was not labeled or dated, and a carton of liquid eggs with no date indicating when it was opened. In addition, there was no internal thermometer in the refrigerator to ensure the unit was keeping items at the correct temperature. 2. A chest type freezer in the kitchen had the corner of the gasket torn and loose on the lid. This had the potential to impede proper sealing and temperature control of the of the unit. 3. During observation of the lunch meal on [DATE], Cook #64 reached into her pocket with a gloved hand, to retrieve . She then used this now contaminated glove to touch hot dog buns. This created a potential for cross contamination. 4. Observations on the south unit dining area revealed foods were not held for service at proper temperatures. Pureed Philly cheese steak sandwiches were 110 degrees F (Fahrenheit), ground chopped steak was 111 degrees F, French fries were 128 degrees F, and milk was 60 degrees F. Safe food handling requires foods be held for service at temperatures which are not in the danger zone, which are temperatures between 41 degrees F and 135 degrees F. 5. Observation of lunch on [DATE] in the south dining room, revealed Cook #64 placed the chopped steak (which was 111 degrees F) into the well of the heatwell unit to reheat the food. Foods cannot be heated in a unit designed to hold foods. They must be heated by methods which rapidly take the food out of the danger zone. A steam table is not designed for heating. It is designed only for holding foods after they have been cooked/heated to the correct temperatures. The temperature of the chopped meat was re-taken 20 minutes after being placed in the heatwell. After 20 minutes, it had only increased 19 degrees F, to 130 degrees F, which was still in the danger zone. 6. Dietary employees were observed preparing and serving foods without effective hair restraints. They wore hats over their hair, but this did not effectively restrain hair which was hanging out the back of the hat. The facility policy entitled Personal hygiene, with an effective date of [DATE], indicated hair restraints were to completely cover hair from front to back. 7. On [DATE], water pitchers were observed on a cart in the north dining room, next to the kitchen, with no protective covering. This was again observed on the morning of [DATE]. This practice created a potential for contamination of the water pitchers as they were exposed to residents and staff who entered and exited the dining room. On [DATE] at 2:30 p.m., dietary staff were observed removing the water pitchers from the clean dish area and placing them on a cart. There was no covering. Dietary Employee #9 stated they used to have a cover for the cart which went over the water pitchers, but did not know what had happened to them. g) Infection Control The facility failed to develop, implement, and maintain an infection control program to prevent and control, to the extent possible, the development and transmission of disease and infection. Residents #55, #109, #147, #221, #34, #33, #226, #69, #64 and #25 had thickened liquids, at their bedsides, in wash basins which were not designated for that use only. Rooms #313, #222, #221, #316, #218, #317, #307, #309, #118, and #211 had soiled items and/or personal care items, which were not assigned to specific residents. Two (2) residents resided in each of these rooms. Their personal care items were co-mingled together in the rooms and/or bathrooms. In addition, residents' water pitchers were not protected from potential contamination. 1. Residents #55, #109, #147, #221, #34, #33, #226, #69, #64, and #25 On [DATE] at 9:30 a.m., these residents had thickened water at their bedsides. The thickened liquids were in containers which were stored in unlabeled wash basins. Some of the wash basins had water and/or ice water which did not appear clean, and some of the wash basins had brown stains. There was no evidence these wash basins were used only for the thickened liquids. In an interview, at 3:33 p.m. on [DATE], the Director of Nursing (DON) stated there was no policy or procedure for labeling the wash basins or for a cleaning schedule to ensure the basins were routinely cleaned and sanitized. She confirmed the wash basins should be for ice only for the thickened liquids, and should be labeled as such. The DON looked at the wash basins and confirmed they were not labeled, but should have been labeled. 2) Rooms #313, #222, #221, #316, #218, #317, #307, #309, #118, and #211 Infection control issues regarding co-mingling of residents' personal care items and/or unclean personal and shared items were observed in residents' rooms. None of the personal care items were labeled or otherwise designated regarding which item belonged to which resident in any of the rooms. Two (2) residents resided in each of rooms in which infection control issues were observed: -- room [ROOM NUMBER] Observation, on [DATE] at 10:20 a.m., found the privacy curtain between the residents' beds was soiled with a brown stain. Items which were not designated by resident name were noted on the bathroom sink and/or on shelves above the sink. This included three (3) bottles of shampoo, a bottle of body wash, two (2) containers of deodorant, and an emesis basin containing a denture brush and toothbrush. On the floor, under the sink, were three (3) wash basins stacked together. A disposable urine container was on the floor. A graduate (used to measure urine from a Foley catheter), with damp paper towels in it, was on the back of the commode. -- room [ROOM NUMBER] Observation of this room, on [DATE] at 2:10 p.m., found a bag of trash, a basket of yarn, and four (4) wash basins stacked together with soiled washcloths in them on the bathroom floor underneath the sink. Also, two (2) wash basins stacked together containing bottles of body wash, deodorant, mousse, curlers, and shampoo were on the sink. There was no designation regarding which items belonged to whom. Items on the ledge above the sink, without designation regarding which items belonged to whom, included a toothbrush, deodorant, body oil, and mouthwash. A graduate, with paper towels in it, was on the back of the commode. -- room [ROOM NUMBER] An observation of room [ROOM NUMBER], on [DATE] at 11:17 a.m., found a graduate, with paper towels in it, on the back of the commode. A water pitcher and glass, without designation regarding which items belonged to whom, were on the bathroom sink. A nebulizer (breathing treatment) machine was found sitting on the floor beside a resident's bed. -- room [ROOM NUMBER] On [DATE] at 1:25 p.m., a red cup containing a toothbrush, shampoo, body wash, two (2) bottles of deodorant, and lotion, without designation regarding which items belonged to whom, were in the bathroom on the sink and/or on shelves above the sink. Also, three (3) wash bas (TRUNCATED)",2018-03-01
7646,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,224,D,1,0,OP4H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, of the facility's reported allegations of abuse/neglect, observation, review of staff assignments, and staff interviews, the facility failed to ensure measures were implemented to prevent neglect for one (1) of nine (9) residents reviewed for the provision of care and services. The resident went without care for an entire shift. He was not turned, changed, and was found with his tube feeding formula all over him and his bed. Nursing staff assignments were not promptly posted at the beginning of each shift to ensure each resident was assigned a caregiver and would receive care. The facility did not always implement a process which ensured nursing staff were made aware of any condition changes and/or assignments. Staff members who were new to the facility were not properly supervised and did not receive assistance as needed to provide care in a timely manner and to ensure residents were not neglected. Resident identifier: #1. Facility Census: 125. Findings Include: a) Resident #1 The medical record for Resident #1 indicated the resident was a quadriplegic. He was totally dependent on staff for all of his activities of daily living (ADLs). Resident #1 received daily treatments for multiple pressure ulcers, had a gastrostomy tube (G/T), an indwelling catheter, a [MEDICAL CONDITION], and multiple contractures. A review of the facility's reported abuse and neglect allegation files revealed an incident which occurred on 11/17/13 involving Resident #1. The resident voiced he had not been turned all day. The facility's investigation included a statement from the nurse who checked the resident and cleaned him up at 3:30 p.m., after the situation was brought to her attention. Her statement was: When assisting CNA (certified nursing assistant) on 11/17/13 at 3:30 p.m. in turning the resident, this nurse observed pillow on left side to have caked tube feeding covering the entirety of the underside. When resident was turned to his right side to remove pillow this nurse observed that the flat sheet had adhered to the air mattress and the resident's back d/t (due to) puddle of dried tube feeding that resident was positioned in. No skin breakdown noted once sheet was removed from skin with warm water. Sheet had to be saturated with water to be removed from air mattress. Resident's wound treatments were completed at this time. Resident was given partial BB (bed bath) and was then repositioned comfortably. No complaints of pain/discomfort. The administrator investigated the incident. She called the nursing assistant (Employee #150) after she determined Employee #150 was assigned to Resident #1 during the day shift on 11/17/13. According to the facility's investigation, the nursing assistant (NA) was made aware the resident said he had not been turned all day. The NA said she provided the resident coffee in his room. The NA also said .she did not normally have him and didn't realize . According to the report, the administrator asked the NA how she could not realize a quadriplegic resident would need assistance with turning? The nursing assistant stated, Well to be honest, I didn't even realize that he was on my assignment until toward the end of my shift. The administrator asked her why she documented in the ADL book that she had provided assistance if she had not. The NA was suspended then terminated. There was no evidence the facility did an investigation to identify each staff member who had interaction with Resident #1 that day, and/or to identify who should have provided necessary care at various times throughout the shift. There were staff members who were responsible for giving his medications, monitoring his catheter and [MEDICAL CONDITION], administering his G/T feeding and flushing, and monitoring his pressure ulcer treatments. There was no evidence any staff member was questioned about this resident's neglect other than Employee #150, the NA. The administrator was questioned about the neglect investigation on 03/21/14 at 2:00 p.m. She verified she had not investigated or considered there was neglect from any staff member other than the NA. She verified the investigation did not include other staff members who should have been caring for the resident or supervising Employee #150. In addition, the administrator said she did not look into the process of staff to resident assignments, even though the NA said she was not aware the resident was on her assignment. b) Staff Assignments and Communication On 03/19/14, a tour of the facility was conducted and the staff assignments were reviewed at 8:30 a.m. This verified the shift for the nursing assistants working at that time started at 7:00 a.m. There was no nurse at the nurses' station and Employee #64 (Social Worker) was asked if she knew where the assignment sheets were for the day. She obtained a sheet and it was noted these assignments were for the prior day, 03/18/14. She looked around the nurses' station and said she did not see another one. Employee #35 (Nursing assistant) was observed at 8:35 a.m. on the South hall picking up breakfast trays. She was asked if she could verify where the assignment sheet for day shift was located. She went to the nurses' station and obtained the same sheet provided by the Social Worker which was the prior day's assignments. She said they must not yet have completed the sheet for today. The nursing assistant verified she had been in the facility since 7:00 a.m. that day. She said sometimes the assignment sheet did not get completed until later. At 8:40 a.m. on 03/19/14, Employee #116 was observed completing the assignment sheet for the South side of the building. She was writing the the names of the staff for each assigned room on the assignment sheet. When interviewed at that time, she verified the assignment sheet was not yet completed. She was asked how everyone knew what to do when they came in, and to which residents they were assigned, so all residents would receive care. She stated, Most of them already know who they are going to have and if they do not know they usually come and ask. This observation was an hour and forty minutes after the nursing assistants came on duty. The assignment sheet on the North Unit was observed at 9:15 a.m. It was completed at that time. It was then verified at 9:50 a.m., this assignment sheet was changed and there was a new assignment sheet completed. Random confidential staff interviews confirmed the assignments were not always posted until later in the shift and not when you first arrived. Staff members said it was often 8:45 a.m. to 9:00 a.m. before it was posted even though their shift began at 7:00 a.m. According to the nursing assistants, sometimes they had the same people and other times it changed because of peoples' preferences or call offs. One staff member stated you had to look at the assignment sheet closely when they posted it because it was not always the same. You may not have who you think you have. They hold assignments for people and people who got there first often got their desired assignment. The person making the assignments had a lot to do with who you got. During one interview, the nursing assistant (NA) was asked to review the assignment sheet and stated, See, now it's already changed, you have to go back and check or you may not know you have someone. It was confirmed the original assignment sheet she had looked at was different, and she had different rooms than earlier. The assignment sheet was observed and verified the rooms were mixed up and the rooms assigned were not always even close together. The nursing assistant verified sometimes you may have one room on one hall and the rest on the other hall and it would be easy to miss someone. One staff member explained the process of assignments and verified it would be easy for a resident to be missed, especially if you did not look at the assignment sheet and recheck it. Random interviews with nursing assistants verified day shift nursing assistants did not even always see the night shift nursing assistants. Sometimes they got report and made rounds with the oncoming shift, sometimes they did not. When asked if they got report from the nurses, they verified they rarely got any type of report. The director of nursing (Employee #2) confirmed, on 03/20/14 at 4:20 p.m., it was the facility's process for report to be given from the nursing assistant leaving to the nursing assistant coming on at each shift change. She said a verbal report should also be given from the nurse to the nursing assistant. She was questioned about the posting of assignments and stated those change so much it was hard to do, but they needed to post them as early as they could. c) Supervision and Assistance The facility was entered at 6:30 a.m. on 03/21/14. The assignments were verified and the nursing assistant (Employee #93) assigned to Resident #1 was interviewed. The nursing assistant stated she was not State-tested (had not taken the required competency test to become registered) yet and would go take her test this week. She said this was her third day on the floor by herself. She verified she had twenty-three (23) residents on her assignment and had not done final rounds on all of her resident's yet. She was observed working by herself until 7:00 a.m. It was verified the nurse supervising the nursing assistant (Employee #93) was Employee #115. She was observed in the hall picking up paper out of the floor and moving carts around at 6:55 a.m. She was never observed checking on Employee #93 from 6:30 a.m. until she left at 7:15 a.m. The nurse was observed going down the hall at 7:20 and stated, I am going home. She did not check to make sure the nursing assistant completed her assignments, or see if further assistance was needed to ensure the residents' care was provided. The Director of Nursing confirmed, on 03/20/14 at 3:00 p.m., Employee #115 would have been the supervisor for Employee #93 that morning. At 7:00 a.m., the day shift nursing assistants were observed arriving. One of the day shift nursing assistants (Employee #107) was observed going into resident rooms with NA Employee #93. She did not assist with completing care, but held two (2) residents on their sides while Employee #93 changed them, provided peri-care, a dry brief, and clean sheets. Employee #93 went to get supplies, then was observed performing peri-care to Resident #51 and Resident #119. It was 7:50 a.m. when she was observed performing incontinence care to Resident #119. The nursing assistant was observed until 8:30 a.m. There were no observations of anyone assisting her to complete care for her twenty-three (23) residents, or supervision to make sure her assignment was completed. She stated she had an extremely busy night and one (1) of her assigned residents passed away that morning, requiring a lot of extra time. The Director of Nursing (Employee # 2) was made aware of the observations that were made the morning of 03/21/14 between the hours of 6:30 a.m. and 8:30 a.m. She verified the nurse supervising Employee #93 should have been Employee #115. She verified the nurse should have made sure the rounds were completed and gotten Employee #93 assistance if she needed it to ensure timely rounds were completed. She verified on the time cards Employee #93 clocked out of the facility at 9:00 a.m., and her supervising nurse, Employee #115, clocked out at 7:23 a.m.",2017-03-01
7647,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,225,D,1,0,OP4H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, a review of the facility's reported allegations of abuse/neglect, and staff interviews, the facility failed to ensure an allegation of neglect for one (1) of six (6) residents reviewed was thoroughly investigated. Resident #1 went without care an entire shift. The facility investigation was not thorough. The investigation did not include all staff members who potentially neglected the resident that day, including nursing staff responsible for supervision of his care. Resident identifier #1. Facility Census: 125. Findings include: a) Resident #1 The medical record for Resident #1 indicated the resident was a quadriplegic. He was totally dependent on staff for all of his activities of daily living (ADLs). Resident #1 received daily treatments for multiple pressure ulcers, had a gastrostomy tube (G/T), an indwelling catheter, a [MEDICAL CONDITION], and multiple contractures. A review of the facility's reported abuse and neglect allegation files revealed an incident which occurred on 11/17/13 involving Resident #1. The resident voiced he had not been turned all day. The facility's investigation included a statement from the nurse who checked the resident and cleaned him up at 3:30 p.m., after the situation was brought to her attention. Her statement was: When assisting CNA (certified nursing assistant) on 11/17/13 at 3:30 p.m. in turning the resident, this nurse observed pillow on left side to have caked tube feeding covering the entirety of the underside. When resident was turned to his right side to remove pillow this nurse observed that the flat sheet had adhered to the air mattress and the resident's back d/t (due to) puddle of dried tube feeding that resident was positioned in. No skin breakdown noted once sheet was removed from skin with warm water. Sheet had to be saturated with water to be removed from air mattress. Resident's wound treatments were completed at this time. Resident was given partial BB (bed bath) and was then repositioned comfortably. No complaints of pain/discomfort. The administrator investigated the incident. She called the nursing assistant (Employee #150) after she determined Employee #150 was assigned to Resident #1 during the day shift on 11/17/13. The investigation of this alleged neglect included only the written statement from the nurse who cleaned up the resident at 3:30 p.m. on 11/17/13, the activity of daily living nursing assistant documentation which indicated care was provided, and the administrator's documentation of the telephone interview with the NA. The facility recognized the resident's care was not provided, even though the NA documented care was provided. According to the facility's investigation, the nursing assistant (NA) was made aware the resident said he had not been turned all day. The NA said she provided the resident coffee in his room. The NA also said .she did not normally have him and didn't realize . According to the report, the administrator asked the NA how she could not realize a quadriplegic resident would need assistance with turning? The nursing assistant stated, Well to be honest, I didn't even realize that he was on my assignment until toward the end of my shift. The administrator asked her why she documented in the ADL book that she had provided assistance if she had not. The NA was suspended then terminated. There was no evidence the facility did an investigation to identify each staff member who had interaction with Resident #1 that day, and/or to identify who should have provided necessary care at various times throughout the shift. There were staff members who were responsible for giving his medications, monitoring his catheter and [MEDICAL CONDITION], administering his G/T feeding and flushing, and monitoring his pressure ulcer treatments. There was no evidence any staff member was questioned about this resident's neglect other than Employee #150, the NA. The administrator was questioned about the neglect investigation on 03/21/14 at 2:00 p.m. She verified she had not investigated or considered there was neglect from any staff member other than the NA. She verified the investigation did not include other staff members who should have been caring for the resident or supervising Employee #150. .",2017-03-01
7648,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,226,D,1,0,OP4H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of allegations of abuse, staff interviews, and review of policies and procedures, the facility failed to implement their written policies and procedures for investigation of abuse/neglect for one (1) of six (6) residents reviewed. The facility did not conduct a thorough investigation and/or an investigation which focused on identification of causative factors as required by their policy. Resident identifier: #1. Facility census: 125 Findings include: a) Resident #1 The medical record for Resident #1 indicated the resident was a quadriplegic. He was totally dependent on staff for all of his activities of daily living (ADLs). Resident #1 received daily treatments for multiple pressure ulcers, had a gastrostomy tube (G/T), an indwelling catheter, a [MEDICAL CONDITION], and multiple contractures. A review of the facility's reported abuse and neglect allegation files revealed an incident which occurred on 11/17/13 involving Resident #1. The resident voiced he had not been turned all day. The facility's investigation included a statement from the nurse who checked the resident and cleaned him up at 3:30 p.m., after the situation was brought to her attention. Her statement was: When assisting CNA (certified nursing assistant) on 11/17/13 at 3:30 p.m. in turning the resident, this nurse observed pillow on left side to have caked tube feeding covering the entirety of the underside. When resident was turned to his right side to remove pillow this nurse observed that the flat sheet had adhered to the air mattress and the resident's back d/t (due to) puddle of dried tube feeding that resident was positioned in. No skin breakdown noted once sheet was removed from skin with warm water. Sheet had to be saturated with water to be removed from air mattress. Resident's wound treatments were completed at this time. Resident was given partial BB (bed bath) and was then repositioned comfortably. No complaints of pain/discomfort. The administrator investigated the incident. She called the nursing assistant (Employee #150) after she determined Employee #150 was assigned to Resident #1 during the day shift on 11/17/13. According to the facility's investigation, the nursing assistant (NA) was made aware the resident said he had not been turned all day. The NA said she provided the resident coffee in his room. The NA also said .she did not normally have him and didn't realize . According to the report, the administrator asked the NA how she could not realize a quadriplegic resident would need assistance with turning? The nursing assistant stated, Well to be honest, I didn't even realize that he was on my assignment until toward the end of my shift. The administrator asked her why she documented in the ADL book that she had provided assistance if she had not. The NA was suspended then terminated. There was no evidence the facility did an investigation to identify each staff member who had interaction with Resident #1 that day, and/or to identify who should have provided necessary care at various times throughout the shift. There were staff members who were responsible for giving his medications, monitoring his catheter and [MEDICAL CONDITION], administering his G/T feeding and flushing, and monitoring his pressure ulcer treatments. There was no evidence any staff member was questioned about this resident's neglect other than Employee #150, the NA. The administrator was questioned about the neglect investigation on 03/21/14 at 2:00 p.m. She verified she had not investigated or considered there was neglect from any staff member other than the NA. She verified the investigation did not include other staff members who should have been caring for the resident or supervising Employee #150. The facility's policy entitled OPS327-WV Abuse Prohibition last revised 07/16/13 stated in section 6.2 conduct an immediate and thorough investigation that focuses on 6.2.3 causative factors and 6.24 interventions to prevent further injury. There was no evidence the facility conducted a thorough investigation to include all staff working with this resident 11/17/13 and had a responsibility for assuring the resident received his care and services. There was no evidence that the causative factors were identified or any evidence changes were made to assure this did not happen again.",2017-03-01
7649,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,241,D,1,0,OP4H11,"Based on observation and policy review, the facility failed to treat Resident #1 with dignity and respect. After applying multiple dressings to the resident's wounds, the nurse wrote the date and her initials on all of the dressings after they were applied to the resident with a permanent marker. This was true for one (1) of one (1) sampled resident observed during wound dressing changes. Resident identifier: #1. Facility Census: 125. Findings Include: a) Resident #1 At 9:40 a.m. on 03/20/14, Employee #31, a registered nurse, did multiple dressing changes to the resident's wounds. The nurse applied dressings to the resident's coccyx, his feet and ankles, both hips, and ischium. After the dressing changes were complete, the treatment nurse (Employee #31), took a permanent black marker and wrote her initials and the date on each of the dressings while Employee #130 (Registered Nurse) assisted with keeping the resident positioned. The facility policy titled NSG246 Wound Dressings, last revised on 01/02/14, stated in section 2.6 under gathering supplies, to gather prepared label with date and initials. The policy stated in section 21.5, to apply prepared label, after the clean dressing was applied.",2017-03-01
7650,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,253,D,1,0,OP4H11,"Based on observation and staff interview, the facility failed to maintain effective housekeeping services. There were dirty walls, dirty beds, a glass with a dried white substance in the bottom sitting on bedside table for an extended period, food on the floor, uncovered fruit in residents' rooms, and a breakfast tray that sat in a room until after 3:00 p.m. This was observed for two (2) of eight (8) sampled residents currently in the building. Resident identifiers #1 and #119. Facility Census: 125. Findings include: a) Resident #1 An observation of Room #112, on 03/20/14 at 2:00 p.m., noted the walls were dirty and had a dark substance above the head of the bed which had dried on the wall. Resident #1's special air bed and the mattress were soiled. Uncovered bananas were in the room. Small black insects were observed flying around the resident. b) Resident #119 An observation of Resident #119's room, on 03/19/14 at 10:00 a.m., found a glass containing a dried white substance on the resident's bedside table. Her breakfast tray was still in her room at that time. Cereal was all over the floor in front of her night stand. The resident also had multiple items sitting on her floor, that included a box of food with chips, cookies, crackers, papers, and a pillow. A bunch of bananas sat on her night stand. Review of the resident's medical record identified the resident did not get up and was totally dependent on staff for care. It was not possible for the resident to put the items on the floor. The resident's room was observed again at 2:00 p.m. on 03/19/14. The room was still the same as at 10:00 a.m. The soiled glass and the breakfast tray were still in her room. Multiple small black flying insects were observed on the walls of the room. The room was checked again on 03/19/14 at 3:30 p.m. The nursing assistant for evening shift (Employee #106), who had come in at 3:00 p.m., was in the room. He verified he removed the resident's breakfast tray when he came in the resident's room at 3:15 p.m. at the beginning of his shift. On 03/20/14 at 7:10 a.m., observation revealed the dry cereal remained on the floor and the box of food was still sitting on the floor. The administrator was made aware of these observations on 03/21/14 at 2:00 p.m. She stated sometimes this resident would not allow you to pick up her breakfast tray. She also confirmed the resident's breakfast tray was still there when lunch trays were served and there was a boiled egg and uncovered cereal on the tray. She agreed the bananas in the resident's room were not in a container, and confirmed the uncovered bananas would encourage pests.",2017-03-01
7651,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,278,D,1,0,OP4H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the minimum data set (MDS) assessment accurately reflected the resident's status. Resident #40's MDS information indicated he had a fracture. It was identified he did not have a fracture and this information was inaccurately coded. The assessment was incorrect for one (1) of nine (9) sample residents. Resident identifier: #40. Facility Census: 125. Findings include: a) Resident #40 The MDS assessment, with an assessment reference date of 02/03/14, was coded as a significant change in status assessment. In Section I, Active Diagnosis, Item I4000 was checked to indicate the resident had an other fracture. Further review of the resident's medical record found no evidence of a fracture. During an interview, on 03/24/14 at 1:00 p.m., a registered nurse (Employee #47) said she completed the MDS assessments. She stated she did not know of this resident having a fracture and she would look into it. On 03/25/14 at 11:00 a.m., the nurse verified the resident had not had a fracture since his admission date of [DATE]. The nurse confirmed the fracture was coded in error and was not an active [DIAGNOSES REDACTED].",2017-03-01
7652,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,279,D,1,0,OP4H11,"Based on record review and staff interview, the facility failed to establish a care plan to include services to be provided to a resident to prevent further decrease in her range of motion. The care plan identified the problem of contractures and decreased range of motion, but there were no interventions or instructions to assist in attaining the goal established in the care plan. This was identified for one (1) of eight (8) sample residents identified with a limitation in range of motion. Resident identifier: #93. Facility Census: 125. Findings include: a) Resident #93 During a review of the medical record, it was identified on a minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/22/14, Item G 0400 indicated the resident had functional limitation in range of motion that interfered with the resident's daily functions. This was identified for the resident's upper and lower extremity on one (1) side. Section S, Item S 3100 of this MDS, identified the resident had contractures of her right hand, right wrist, right elbow, right shoulder, right knee and contractures of both ankles. The care plan for the resident indicated it was last revised on 01/27/14. The care plan focus stated this resident . is at risk for alterations in her functional mobility related to right shoulder, elbow, wrist, and ankle contractures as well as her decreased ROM (range of motion) to her RUE (right upper extremity). The goal for this problem stated the resident . will not have any decrease in her ROM (range of motion) over the next review period. The only intervention for the goal was observe (Resident #93) for pain, stiffness: medicate as ordered and report to physician as indicated. There were no interventions to assist the resident in attaining the goal to not having a decrease in range of motion. Employee #32, a nursing assistant, was interviewed on 03/25/14 at 3:00 p.m. She stated the range of motion services were provided during the care of Resident #93. She described this resident's limitations and contractures and the process in which they perform gentle range of motion to prevent further decline during her care. The Director of Nursing was interviewed 03/25/14 at 3:15. She verified there were no interventions in the care plan describing the services to be provided relative to preventing a further decline in this resident's range of motion. ,",2017-03-01
7653,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,280,D,1,0,OP4H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise care plans after the residents' treatments changed significantly. Resident #1's treatment plan changed to palliative care care. The resident was no longer to be weighed or have laboratory work (labs). His care plan included interventions to complete laboratory procedures. Resident #15's care plan was not revised after the physician changed how often she needed to be catheterized. The care plans were not revised for two (2) of nine (9) sampled residents. Resident identifiers: Resident #1 and Resident #15. Facility Census: 125. Findings include: a) Resident #1 The nursing notes, dated 10/18/13, reflected Resident #1's responsible party wished to change the resident's care to palliative care. The facility was no longer to obtain weights and lab work. The responsible party also requested intravenous antibiotics be discontinued and the resident provided with comfort care only. A physician's orders [REDACTED]. A review of the care plan revealed it was not revised to discontinue the following interventions which were no longer appropriate for the resident: 1) A care plan with a target date of 04/17/14 for dehydration, had an contained an intervention revised 12/20/13 that stated to observe for s/s (signs and symptoms) of infections and report as indicated. Obtain labs and cultures as ordered and report to physician. 2) Another intervention in Resident #1's care plan stated, Obtain therapeutic lab values per order: [MEDICATION NAME] every 30 days, CBC ( complete blood count) every three (3) months, Lipids every six (6) months and a CMP (complete metabolic profile) every three (3) months. This intervention was dated as revised 12/30/13. 3) The same care plan contained a focus that stated, Resident/health care decision maker has expressed desire for palliative /comfort care measures related to other: no labs, no weight, as of 10/22/13. The goal for this focus stated Resident will not have labs or weights obtained while in the facility. An interview was conducted with Employee #47 on 03/20/14 at 2:30 p.m. She confirmed the care plan was not revised related to laboratory interventions and weights. b) Resident #15 A review of the resident's current care plan found a problem related to the need for staff to straight catheterize her twice a shift as ordered related to history of [MEDICAL CONDITION] bladder. The care plan indicated it was initiated on 10/11/13 and was last revised on 01/03/14. Further review of the medical record found a physician's orders [REDACTED]. The Director of Nursing (Employee #2) was interviewed 03/24/14 at 3:30 p.m. She verified the resident's treatment plan changed and the resident was only to be straight catheterized every shift instead of twice a shift as of 10/27/13. She verified the resident's care plan was not revised to reflect this change in the treatment, and the information in the care plan was incorrect.",2017-03-01
7654,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,309,D,1,0,OP4H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure pain was adequately assessed and monitored. In addition, there was no evidence non-pharmacological interventions were attempted, prior to use of as needed (PRN) medications, for one (1) of one (1) sample resident who expressed pain. Resident identifier: #1 . Facility Census: 125. Findings Include: a) Resident #1 During an interview with Resident #1, on 03/19/14 at 10:00 a.m., he was questioned about his comfort. He stated he had pain all the time. He said they gave him medication but he still had pain. The medical record for Resident #1 was reviewed on 03/19/14 . His record indicated the resident was alert and oriented. He was a [AGE] year old quadriplegic, totally dependent for all activities of daily living (ADLs), was receiving daily treatments for multiple pressure ulcers, had a gastrostomy tube, an indwelling catheter, a [MEDICAL CONDITION], and multiple contractures. He had a [DIAGNOSES REDACTED]. The physician orders [REDACTED]. If the answer was Y (yes) then the interventions were to be documented. A review of the resident's physician orders [REDACTED]. The patch was ordered to be applied every 72 hours for pain. He also received [MEDICATION NAME] sulfate Solution 0.5 ml sublingually every four (4) hours as needed (PRN) for pain. Non-pharmaceutical interventions included: 1 = Reposition, 2 = offer fluids/snacks, and 3 = give back rub. If the resident refused the interventions, documentation was to be 4 = Refused. The effectiveness of the interventions was to be documented as: effective Y (yes) or N (no). The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. If Yes, document interventions. There were ten (10) Ys recorded and ten (10) Ns recorded during the first twenty days of March. Further review of the MAR indicated [REDACTED]. There was no evidence non-pharmacological interventions were attempted prior to each of the 37 times the medication was administered. Facility records indicated PRN medications were documented on a form designed specifically for recording non-pharmaceutical interventions. It had codes to be used for each of the interventions attempted. Only three (3) non-pharmacological interventions were recorded for the use of the 37 PRN medications for the month of March. The resident's pain medication was reviewed for the month of February 2014. This MAR indicated [REDACTED]. There were only seven (7) times a non-pharmaceutical intervention was recorded for pain for the 53 times the medication was administered. The Director of Nursing (DON) was interviewed on 03/21/14 at 2:00 p.m. She said if PRN pain medications were administered, the facility practice was to document the non-pharmacological interventions provided on the flow sheet. The DON verified, for the month of March, there was evidence of non-pharmacological interventions only three (3) times, but the medication was administered 37 times. When questioned about pain assessments, and where the location and severity of pain were recorded, the DON said this should be assessed and recorded when the pain medication was administered. She confirmed the effectiveness was also to be assessed and recorded. The DON verified this was not done in February or March. She also verified the implementation of non-pharmacological interventions was not evident for each use of the PRN medication. The DON stated the facility pain management policy was not consistently being implemented.",2017-03-01
7655,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,314,D,1,0,OP4H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to provide services and treatments as ordered by the physician to promote the healing of pressure ulcers. Physician orders [REDACTED]. This had the potential to impede the healing of the resident's pressure ulcers. This was found for one (1) of four (4) sampled residents who had pressure ulcers at the time of the survey. Resident identifier: #1. Facility Census: #125. Findings Include: a) Resident #1 --Review of Resident #1's medical record found the resident had physician's orders [REDACTED]. 1. Cleanse left distal foot with wound cleanser, pat dry, apply hydrogel and dry dressing. Change q (every) three (3) days. 2. Cleanse right distal foot with wound cleanser, pat dry, apply protective dressing. Change q (every) three (3) days. 3. Cleanse right heel with wound cleanser, pat dry, apply hydrogel and dry dressing, change q (every) three (3) days. 4. Cleanse right Iliac with wound cleanser, pat dry and apply protective dressing. Change on Tuesday and Friday. 5. Cleanse right outer ankle with wound cleanser. Pat dry, apply sureprep, cover with protective dressing change q (every) three days. 6. Cleanse left elbow with wound cleanser, pat dry, apply dry dressing. change q 3 days. 7. Cleanse left heel with wound cleanser, pat dry, apply dry dressing. Change q (every) three (3) days. 8. Cleanse left hip (site # 3) with wound cleanser, pat dry, apply sureprep q (every) shift. Cover with [MEDICATION NAME] gentle change daily. 9. Cleanse left iliac with wound cleanser, pat dry, apply protective dressing. 10. Cleanse left inner foot with wound cleanser, pat dry and apply dry dressing, change q 3 days. 11. Cleanse left ischium with wound cleanser, pat dry, apply sureprep to periwound. Apply [MEDICATION NAME] and cover with [MEDICATION NAME]. Change BID (twice a day). 12. Cleanse left outer ankle with wound cleanser, pat dry, apply hydrogel and dry dressing. Change q 3 days. 13. Cleanse left outer midfoot with wound cleanser, pat dry, apply sureprep cover with protective dressing. Change q 3 days. 14. Cleanse right Ishcium with wound cleanser, pat dry, apply sureprep, apply [MEDICATION NAME], cover with [MEDICATION NAME], change q (every) day. Observation of the dressing changes to the resident's wounds, on 03/20/14 at 9:40 a.m., found the nurse did not adequately cleanse each wound, even though each of the orders included to cleanse the wound with wound cleanser and pat dry. The purpose of cleaning with wound cleanser and patting the area dry is to remove debris and microbes from the wound's surface. The nurse only sprayed the center of each of the areas with a small amount of wound cleanser. She then touched a 4x4 (four by four) dressing to the area one time and removed it, then applied the new dressings. Observation revealed the nurse did not clean the entire wound from inner to outer edges, but only cleansed the center of the wounds. The outer edges of the wounds were not cleansed prior to applying the new dressing. The nurse also did not pat dry as ordered by the physician, but instead touched the wound one (1) time in the center prior to applying the new dressing. This process of cleaning was observed for each of the resident's wounds. On 03/25/14 at 2:00 p.m., the treatment nurse was made aware of the concerns regarding the cleansing of the wounds. She agreed the entire wound should be cleansed from the inner to the outer part of the wound to ensure the entire wound was cleansed. She also verified she only touched the center of the wound and did not pat dry as ordered. --Specialty Bed for Wound Healing Further review of the resident's physician's orders [REDACTED]. Observations, on 03/20/14 at 9:40 a.m., noted the setting on the bed was on 5 and not on 4 as ordered by the physician. (A Flap Care Bed is a bed that provides pressure relief by combining low air loss with pulsation. The settings are individualized to ensure proper inflation of the air cells and prevent bottoming out of the mattress.) Employee #2, the director of nursing (DON) was made aware of the bed observation at 11:00 a.m. on 3/20/14. She verified the bed was not on the proper setting and described how the nurses were supposed to perform hand checks every week to ensure proper setting, inflation, and functioning. Review of the medical record revealed a new physician's orders [REDACTED]. The order for the Flap Care Bed had a discontinuation of the setting at four (4), and now had an order for [REDACTED]. --Gastrostomy Feeding for Wound Healing A physician's orders [REDACTED].@ 45 ml/hr (milliliters per hour) for 16 hours for supplemental nutrition. According to the enteral protocol sheet, the resident's feedings were scheduled to be turned on at 45 ml/hr at 6:00 p.m. and turned off at 10:00 a.m. On 03/21/14, review of the dietitian's assessment found the resident was ordered Two Cal HN @ 45 ml /hr 16 hours each day. The dietary assessment stated the primary [DIAGNOSES REDACTED]. Observations on 03/20/14 revealed the facility failed to ensure the resident was provided the amount of Two Cal HN as ordered. At 7:30 a.m., observations found the tube feeding was turned off and the resident taken to the shower. When he was returned to his room, at 7:45 a.m., the gastrostomy tube ([DEVICE]) feeding was not restarted to run until its scheduled stop time of 10:00 a.m. At 12:00 p.m. on 03/20/14, the Licensed Practical Nurse (LPN), Employee #62, was interviewed about this resident's feeding rate and how the facility monitored it to ensure he received the amount of feeding as ordered. She stated they documented when they turn it on and when they turn it off, but they do not record the actual amount of feeding he received. She said I always turn it off at 10:00 a.m. When she was made aware the feeding was turned off at 7:30 a.m. and not turned back on, she stated, I forgot to document it, but I turned it off when he went to the shower and he did not want it back on. At that time, she took the treatment sheet and initialed it and circled her initials. On the back of the sheet she wrote the date of 03/20/14 and Wanted tube feeding off at 7:30 A d/t (due to) bath and dressing (symbol for change). She then stated, He gets a tray also and he gets his feeding for his wounds.",2017-03-01
7656,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,315,D,1,0,OP4H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure three (3) of nine (9) sample residents received appropriate services to prevent urinary tract infections (UTIs). Resident #1, for whom there was no evidence of a catheter change for five (5) months, was observed with sediment in the catheter tubing and the urine in the drainage bag was dark and cloudy, indicating a potential UTI. In addition, proper hygiene measures were not implemented when providing incontinence care to Resident #51 and Resident #119 to prevent a urinary tract infections. Resident identifiers: #1, # 51, and #119. Facility Census: 125. Findings include: a) Resident #1 During an observation of Resident #1's dressing changes, at 9:40 a.m. 03/20/14, it was noted this resident had an indwelling catheter present. The tubing from the catheter to the drainage bag had a large amount of sediment. The urine in the catheter drainage bag was dark and very cloudy. When Employee #130 (Registered Nurse) was asked about the catheter, she agreed the urine was cloudy and the tubing contained sediment. The nurse was questioned how often the catheter was changed for the resident. She verified in the medical record the catheter was only changed as needed. The nurse phoned the physician at that time and obtained an order to obtain a urinalysis (UA) due to the cloudy urine. The urinalysis was completed and the indwelling catheter was changed on 03/20/14. The medical record was reviewed to determine when this catheter was last changed. The director of nursing (DON) verified, on 03/20/14 at 3:00 p.m., the last time it was changed was 10/14/13 (more than five (5) months ago). It was recorded on 10/18/13 the #16 french Foley catheter was changed, cloudy yellow urine obtained for urinalysis culture and sensitivity. The resident was afebrile at that time. The resident's laboratory data, on 10/14/14, indicated the resident had a UTI at that time. He had just recently completed antibiotics. The care plan for this resident identified he was at risk for complications related to his indwelling catheter due to his impaired skin integrity and history of [MEDICAL CONDITION]. The care plan goal stated his Foley catheter would remain patent over the next review period. The interventions stated change Foley catheter when dysfunction or PRN (as needed). It was not clear when PRN (as needed) would be. The interventions stated to observe (Resident #1) for s/s (signs and symptoms) of a probable UTI (urinary tract infection) such as : fever, decreased urinary output, foul smelling urine, sediment or blood in urine, decreased LOC (level of consciousness) or increased behaviors etc & report. There was no evidence the facility identified the cloudy urine or the sediment in the tubing or reported this to the physician prior to the observation during the survey on 03/20/14. b) Resident # 51 Employee #93 was observed making her final rounds prior to the end of her shift at 7:10 a.m. on 03/20/14. She was observed performing incontinence care on Resident #51. Employee #93 was observed to cleanse the resident's outer skin folds by the top of her legs wiping gently with peri-lotion. She did not attempt to cleanse the inner skin folds or separate or clean the inner labia area. c) Resident # 119 Nurse aide (NA), Employee #93 was observed at 7:40 a.m. on 03/20/14 while providing peri-care for Resident #119. She was observed to gently cleanse the resident's outer skin folds by the top of her legs, wiping gently with peri-lotion. She did not attempt to cleanse the inner skin folds or separate or clean the inner labia area. Employee #107, NA, assisted Employee #93 by holding the resident on her side while Employee #93 cleansed her. When the resident was turned to her side, she had feces on her and had a bowel movement on the bed. While Employee #107 held the resident on her side, Employee #93 cleaned the feces from the resident by wiping from the anal area toward the front, toward the urethra. By wiping from front to back, bacteria from the anal area can be transferred to the urethra, creating a potential to cause urinary tract infections. The director of nursing (Employee #2) was made aware of the observations regarding the improper technique for peri-care observed for Residents #51 and #119 on 03/20/14 at 4:00 p.m.",2017-03-01
7657,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,318,D,1,0,OP4H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to ensure a resident with existing contractures was provided services to increase range of motion (ROM) and/or to prevent further decrease in ROM. The splint for one (1) resident observed with a splinting device ordered to treat a contracture was not applied as ordered. Resident identifier: #40. Facility Census: #125. Findings include: a) Resident #40 Review of the resident's medical record found the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/21/14, indicated in Item G0400 this resident had impairments of functional limitation of his upper extremities and lower extremities on both sides. It was also identified in Section S he had contractures present of both hands, both wrists, both elbows, both shoulders, and both ankles. He received specific range of motion of his extremities and he had a physician's orders [REDACTED]. A review of this resident's care plan, last revised on 01/27/14, identified he had contractures and decreased range of motion. His goal was, . will not have any increase in his contractures over the next review period. The target date for this goal was 05/04/14. The interventions for this goal stated, Apply right hand splint at 8:00 a.m. and remove at 12:00 p.m. Check skin integrity upon removal of right hand splint every shift. This care plan also contained directions that stated prior to applying right hand splint, ensure placement of geri-sleeve under right hand splint at all times before applying it. Observations made at 9:40 a.m. on 03/25/14 revealed Resident #40 was in bed asleep. He did not have a splinting device on his hand as ordered. The nursing assistant providing his care at that time (Employee #39) was interviewed and she stated this resident's splint does not have to be put on until 10:00 a.m. and then it was removed at lunch time when he eats. The resident was observed again at 10:45 a.m. He had the splint on his right hand at that time but it was observed there was no geri-sleeve on underneath it as ordered. The director of nursing (Employee #2 ) was interviewed at 10:45 a.m. on 03/25/14. She was made aware of the observation and the splint not being applied at the time it was ordered. She clarified this issue and stated the splint should have been applied at 8:00 a.m. and there should have been a geri-sleeve applied under the splint. She verified this was not applied as ordered by the physician.",2017-03-01
7658,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,323,E,1,0,OP4H11,"Based on observation and staff interview, the facility failed to ensure the environment was as free of accident hazards as possible. An unlocked and unattended medication cart was observed in the hall on the North unit. Residents were in the vicinity of the cart at that time, providing an opportunity for residents to access the contents of the cart. This had the potential to affect more than an isolated number of residents on the North Unit. North Unit Census: 49. Facility Census: 125. Findings include: a) Medication Cart On 03/25/14 at 4:13 p.m., on the North unit beside of Room 105, a medication cart was observed unattended in the hallway. Observation revealed it was also unlocked. The medication cart was continually observed for three (3) minutes, from 4:13 p.m. until 4:16 p.m. There were multiple residents observed in the hall walking past the cart. At 4:16 p.m. on 03/25/14, licensed practical nurse (Employee #140) came down the hall from the nurses' station. She was made aware her cart was left unlocked and unsupervised in the hall. Employee #140 stated she was aware she should not leave the cart unlocked, but she had an emergency. The director of nursing (Employee #2) was made aware of the observation of the unattended and unlocked medication cart on 03/25/14 at 4:30 p.m. She stated she had just discussed the issue with the medication carts being unlocked at the last nurse's meeting.",2017-03-01
7659,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,325,D,1,0,OP4H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure nutritional care was provided according to the resident's assessed needs. The dietitian's nutritional assessment and the physician's orders [REDACTED].#1 required to meet his nutritional needs. The tube feeding was not administered as ordered. The facility had no system in place to monitor the actual amount of tube feeding the resident received each day. This was identified for one (1) of two (2) sample residents who had orders for tube feedings to be administered during specific hours each day. Resident identifier: #1. Facility Census: 125. Findings Include: a) Resident #1 A physician's orders [REDACTED].@ 45 ml/hr (milliliters per hour) for sixteen (16) hours for supplemental nutrition. According to the enternal protocol sheet, the resident's feeding was scheduled to be started at 6:00 p.m. at 45 ml/hr and turned off at 10:00 a.m. That would be 720 ml of the tube feeding formula in 16 hours, which would be 1440 calories . On 03/20/14 at 7:30 a.m., the tube feeding was turned off when the resident was taken to the shower. When he returned to his room, at 7:45 a.m., the tube feeding was not turned back on. Observation revealed it remained off from 7:30 a.m. until 10:00 a.m., resulting in the resident not receiving 112.5 ml of the tube feeding, or 224 calories. At 12:00 p.m. on 03/20/14, the Licensed Practical Nurse (LPN), Employee #62, was interviewed about this resident's feeding rate and how the facility monitored it to ensure he received the amount of feeding as ordered. She stated they documented when they turn it on and when they turn it off, but they do not record the actual amount of feeding he received. She said I always turn it off at 10:00 a.m. When she was made aware the feeding was turned off at 7:30 a.m. and not turned back on, she stated, I forgot to document it, but I turned it off when he went to the shower and he did not want it back on. During the interview, the nurse stated the resident sometimes refused to have the tube feeding turned back on after his shower. At that time, Employee #62 documented for 03/20/14. She initialed it and circled her initials. On the back of the sheet she wrote the date of 03/20/14 and Wanted tube feeding off at 7:30 A d/t (due to) bath and dressing (symbol for change). She stated, He gets a tray also and he gets his feeding for his wounds. On 03/21/14, review of the dietitian's assessment found the resident's diet order was a regular diet. He also was to receive a tube feeding of the product Two Cal HN @ 45 ml /hr 16 hours each day. The total volume of product to be received in 24 hours was 720 ml . He also was to receive 200 ml of water flush every six (6) hours. The dietary assessment stated the primary [DIAGNOSES REDACTED]. The assessment included his protein needs were 81 gm a day. His calorie needs were 1620 calories each day. According to his nutritional assessment he received 60 gm protein in his feeding if he accepted his feeding each day. He received a regular diet by mouth each meal, snacks, and it was recorded his family brought him food when they visited. A review of the abuse/neglect files, revealed on 11/17/13 Resident #1 was found with his tube feeding covering the entirety of the underside of the resident. The feeding was dried. His sheet had adhered to the air mattress and the resident's back. The resident was positioned on an area of dried tube feeding. This had to be removed from his skin with warm water. The enteral feeding record for 11/17/13 was reviewed. It indicated his feeding was administered as ordered. There was nothing in the record which indicated the resident did not receive the tube feeding because it had leaked onto the resident and onto his bed. The enteral feeding sheet for November 2013 stated he was to receive 720 ml at the rate of 45 ml per hour. This did not occur on 11/17/13; however, the record reflected the resident received the tube feeding as ordered. The director of nursing (DON) was interviewed, on 03/20/14 at 2:00 p.m., regarding the facility's process for making sure residents received tube feedings as ordered. She said the facility did not do intake and output monitoring unless it was ordered by the physician. She was asked how the the facility monitored the the amount of tube feeding formula administered each day, and how they knew residents received the amount as ordered. The DON said they did not utilize the administration pump to monitor the amount of feeding administered. She said it was just the facility's practice to turn it on and off at a specific time. She was made aware of the two (2) occasions identified when the resident did not receive his feeding as ordered, and the fact staff said at times the resident would not allow the tube feeding to be turned on. The DON said the facility did not have an accurate account of the amount of intake the resident received daily. She stated if he did not get the feeding, the nurses should document this at the time he refused it.",2017-03-01
7660,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,441,E,1,0,OP4H11,"Based on observation and staff interview, the facility failed to ensure a sanitary environment to prevent the spread of infectious organisms. Soiled gloves were used in a manner that would transmit organisms throughout the North Unit of the building. Dirty soiled gloves were used when touching items in residents' rooms, door knobs, key pads to unlock doors, the bottle of cleaning lotion used to provide peri-care, and the nursing assistant's uniform. Two (2) residents were affected; however, this practice had the potential to affect more than an isolated number of residents. Resident identifiers: #51 and #119 Facility Census on the North Unit: 49. Facility Census: 125. Findings include: a) Resident #51 An observation of this resident's care after an episode of urinary incontinence was made on 03/20/14 at 7:10 a.m. The nursing assistant (Employee #93) had a container of peri-care lotion in her pocket. She placed the lotion on the resident's bed. She applied her gloves, provided incontinence care to the resident, then after cleaning the resident's peri-area and changing the brief soiled with urine, she did not remove her gloves. She touched other items in the resident's environment. She positioned the resident's pillow and sheets while wearing the contaminated gloves, then picked up the peri-lotion with the same soiled gloves. She then put the peri-lotion bottle in her pocket contaminating her clothing with the contaminated bottle. At 7:30 a.m. Employee #93, after providing peri-care to Resident #51, wore the contaminated gloves up the hall into the room where the trash was kept. She unlocked the door, touched the door knob, and threw away the trash. Then she went to the laundry room at the end of the hall and opened the door of that room while wearing the same soiled gloves, contaminating the door knob of that room also. b) Resident #119 During observation of incontinence care for this resident, at 7:40 a.m. on 03/20/14, Employee #93 (nursing assistant) was observed to remove the peri-care lotion from her uniform pocket. This was the same lotion she had just used and touched with soiled gloves during the incontinence care she provided Resident #51. She applied clean gloves, then provided incontinence care to this resident. When the resident was rolled to her side, she had feces on her from a bowel movement. The nursing assistant started cleaning the feces from the resident with a washcloth. A second nursing assistant (Employee #107) provided assistance by holding the resident on her side. Employee #107 informed Employee #93 the resident had cleansing wipes on top of her cabinet. The nursing assistant, wearing the same gloves hands with which she had just cleaned feces from the resident, reached up on the cabinet and got the container of wipes. This , contaminated the container. She also touched other items on the resident's bedside table and the resident's glasses with the contaminated gloves. Employee #93 removed the cleansing lotion from her pocket she had contaminated during care for Resident #51, and started cleaning Resident #119 with it. At that time, Employee #107 told her the resident had a tube of cream in her drawer which the resident liked applied. While wearing the same glove she had worn to clean feces from the resident, Employee #93 put the incontinence care lotion back in her pocket, opened the resident's drawer, took out the tube of cream, and put it on the resident. This created a potential for contamination, with potentially pathogenic microorganisms, of all the objects with which Employee #93 had contact. The nursing assistant (Employee #93) threw the wipes and the washcloths covered with feces in the same bag. After she finished this resident's incontinence care, while still wearing the same contaminated gloves, she took the bag to the soiled utility room where the trash was kept. She opened the door to this room, sorted the wipes, which were to be thrown in the trash, from the washcloths which needed to go to the laundry. Both the wipes and the washcloths were covered with feces. Still wearing the soiled gloves, she opened the door and took the washcloths to the laundry room at the end of the hall. She did not remove the soiled gloves and wash her hands until after she opened the laundry room door and took in the dirty laundry. On 03/20/14 at 4:00 p.m., the director of nursing (Employee #2) and the Administrator were made aware of the observations of Employee #93 and her breaches of infection control practices in the use of gloves and lack of hand washing. The administrator presented Employee #93's employee check off list dated 02/25/14. This list identified the employee had gone through training, including infection control and hand washing. .",2017-03-01
7661,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,469,E,1,0,OP4H11,"Based on observation, resident interview, and staff interview, the facility failed to ensure a pest control program which contained measures to eradicate the problems which resulted in pest infestation. Insects were observed flying about residents' faces and personal spaces, and were on the ceilings and walls. Insect attractants, such as uncovered foods and/or smokeless tobacco spit, were observed in three (3) of eight (8) sample residents' rooms. Resident identifiers: #119, #1, and #71. This had the potential to affect more than an isolated number of residents in the facility. Facility Census: 125. Findings include: a) Resident #119 During an interview, on 03/19/14 at 10:00 a.m., with Resident #119, she stated she Sees bugs all the time, but people tell her she is crazy and there is no bugs. The resident confirmed she required staff to care for her. She said she stays in the bed most of the time and cannot walk. She said the bugs really bother her. At that time, black dots were observed on the ceiling and the walls. They were observed on 03/19/14 while conversing with the resident, but were not observed to move at that time. An ink pen was then used to touch the black dots and they flew, confirming these were bugs. There were five (5) small black flying insects observed in the resident's room. Further observation, on 03/19/14 at 10:00 a.m., of the resident's room found her breakfast tray sitting in the chair by the window. It had an uneaten boiled egg and cereal on the tray. There was food spilled on the floor and bananas were sitting on her nightstand uncovered. b) Resident #1 During an interview with this resident, on 03/19/14 at 2:00 p.m., he had black substance in his teeth and was spitting in an emesis basin. When asked if he was chewing tobacco, he stated No it is Skoal. Small flying insects were flying around the resident during this conversation. This resident was quadriplegic and unable to use his arms or legs. He was totally dependent on staff for care. An observation in Resident #1's room on 03/20/14 at 10:00 a.m., again found small black insects flying around in the resident's room. There was a piece of pineapple upside down cake on the dresser covered with plastic and these small insects were observed on top. Uncovered bananas sat on the table in the corner of the room. When the resident was asked, on 03/20/14 at 11:00 a.m., about whether the the insects in his room bothered him, he said, Yes, and said he sees them all the time. c) Resident #71 During an interview with this resident, on 03/21/14 at 8:230 a.m., small black insects were flying around the resident. When asked about the insects, he stated, They really bother me because I am not even able to use my arms to swat them away. He verified this had been an issue lately. He said, They always fly around my face. d) The administrator was interviewed on 03/20/14 at 2:00 p.m. She verified they had a pest control company that came to the facility on a regular basis. It was verified the pest control company had last been there on 03/18/14. There was no evidence the pest control company was informed of the issue with the small black flying insects. The written report provided by the pest control company said, Large amounts of food and tobacco on the floor. Uncovered food and/or an emesis basin containing tobacco spit was observed in the residents' rooms in which the small black flying insects were observed.",2017-03-01
7662,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,498,E,1,0,OP4H11,"Based on observation and staff interview, the facility failed to ensure a nursing assistant (NA) demonstrated competency in skills and techniques while providing care to the residents. A nurse aide did not provide incontinence care in a manner consistent with recognized infection control practices. The NA applied a medicated cream which was not ordered and required a licensed nurse to apply if it had been ordered. The NA's lack of competency affected two (2) resident and had the potential to affect all residents on the North Unit. Resident identifiers: #51 and #119. North Census: 49. Facility Census: 125. Findings include: a) Resident # 51 Observation revealed Employee #93, a nursing assistant (NA) had a container of peri-care lotion in her pocket. She laid the lotion on the resident's bed, applied her gloves, and provided incontinence care to the resident. She was observed to cleanse the residents outer skin folds by the top of her legs wiping gently with peri-lotion. There was no cleansing observed of the inner skin folds and she did not separate or clean the inner labia area. Failure to cleanse this area after a resident is incontinent had the potential result in a urinary tract infection from providing inadequate hygiene. After cleaning the resident's peri-area and changing the brief soiled with urine, the NA did not remove her gloves. She touched other items in the resident's room, fixed her pillow and sheets, then picked up the peri-lotion with her contaminated gloves. She then put the peri-lotion bottle in her pocket, contaminating her clothing with the soiled bottle. After providing Resident #51's peri-care, Employee # 93 was observed, at 7:30 a.m., wearing the dirty gloves into the room where the trash was kept. While still wearing the diret gloves, she unlocked the door, touched the door knob, and threw away the trash. Further observation revealed Employe #93 went to the laundry room and opened the door of that room wearing the same dirty gloves. b) Resident #119 An observation was made at 7:40 a.m. on 03/20/14 of this resident's incontinence care. Employee #93 (nursing assistant) was observed to remove the peri-care lotion from her uniform pocket she had just used and touched with soiled gloves during the incontinence care she provided Resident #51. She applied clean gloves and cleansed the resident's outer skin folds with peri-lotion. She did not attempt to cleanse the inner skin folds or separate and clean the inner labia area. This practice allowed urine to remain in that area potentially causing complications. Employee #107 (nursing assistant) was observed assisting by holding the resident on her side, while Employee #93 cleansed her. When the resident was turned to her side, she was observed with had feces on her. While Employee #107 held the resident to the side, the nursing assistant was observed to clean the feces from the resident. She wiped from the anal area toward the urethra (back to front instead of front to back). This procedure can transfer bacteria from the anal area to the urethra, creating the potential to cause urinary tract infections. Employee # 93 (nursing assistant) cleansed the feces from the resident with a washcloth. The other nursing assistant (Employee #107), who was providing assistance, informed Employee #93 this resident had cleansing wipes on top of her cabinet. Employee #93 reached to the top of the cabinet wearing the same gloves with which she had just cleaned feces from the resident, and obtained the container of wipes. This contaminated the container of cleansing wipes. She was also observed touching other items on the resident's bed side table and the resident's glasses with these contaminated gloves. She removed the cleansing lotion from her pocket, which she had contaminated while providing care to Resident #51, and started cleaning Resident #119. Employee #107 told Employe #93 the resident had a tube of cream in her drawer which she liked used on her. Employee #93 then put the incontinence care lotion back in her pocket (after touching in with the gloves she wiped feces with) then opened the drawer of her cabinet with the same gloves and took out the tube of cream and put it on the resident. The nursing assistant (Employee # 93) was observed to throw the wipes and the washcloths covered with feces in the same bag . After she finished with this resident's incontinence care, she then took the bag and went to the soiled utility room where the trash is kept and opened the door to this room with the same dirty gloves still on . She sorted the wipes which were to be thrown in the trash, from the washcloths which needed to go to the laundry. Both were covered with feces as she sorted these. She then opened the door and took the wash clothes to the laundry room at the end of the hall with the same gloves. She opened the laundry room door and took the dirty laundry in. She then removed her gloves and washed her hands. The director of nursing (Employee #2) was made aware the observations including inadequate peri-care and the infection control practices on 03/20/14 at 4:00 p.m. She stated Employee #93 was new and had recently completed the nursing assistant class and was not state tested yet. She confirmed the Employee had been checked off during orientation that she could complete adequate hygiene. She was made aware the nursing assistant assisting her (Employee #107) instructed her regarding which cream the resident liked to be applied. The director of nursing (Employee #2) verified there was no physician's order to apply this cream and this medicated cream should be applied a nurse and not a nursing assistant.",2017-03-01
7663,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,514,D,1,0,OP4H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medical record was accurate and complete for one (1) of nine (9) sample residents. The medical record reflected tube feedings and water flushes were administered as ordered; however, the resident did not always receive the feeding as ordered. Resident identifier: #1. Facility Census: 125. Findings include: a) Resident #1 A physician's orders [REDACTED].#1 was to receive Two Cal HN @ 45 ml/hr (milliliters per hour) for sixteen (16) hours for supplemental nutrition. According to the dietitian's assessment, the resident was also to receive 200 ml of water every six (6) hours. The enternal protocol sheet indicated the resident's feeding was scheduled to be turned on at 6:00 p.m. at 45 ml/hr. It was to be turned off at 10:00 a.m. On 03/20/14 at 7:30 a.m., the tube feeding was observed turned off when the resident was taken to the shower. When he returned to his room, at 7:45 a.m., the tube feeding was not turned back on to continue until 10:00 a.m. as ordered. At 12:00 p.m. on 03/20/14 the treatment record (TAR) was reviewed. There was no documentation regarding how much feeding the resident received, nor was there documentation regarding the feeding being turned off and left off on 03/20/14. The Licensed Practical Nurse (LPN), Employee #62, was interviewed about the resident's tube feeding rate and how the facility monitored the tube feeding formula and water to ensure he received the full amounts as ordered. She stated they documented when the tube feeding was turned on and when it was turned off. The LPN said the actual amount of fluid provided was not recorded. Employee #62 said, I always turn it off right at 10:00 a.m. She was asked about the tube feeding provided that day (03/20/14). At that time she was informed it was turned off at 7:30 a.m., and was not turned back on. Employee #62 stated, I forgot to document it, but I turned it off when he went to the shower and he did not want it back on. At that time, observation revealed Employee #62 documented for 03/20/14 on the treatment sheet. She initialed it, circled her initials, and wrote (on the back side of the sheet) Wanted tube feeding off at 7:30 A d/t (due to) bath and dressing (symbol for change). She then stated, He gets a tray also and he gets his feeding for his wounds. During the survey, Employee #76, the nursing assistant who provided the resident's shower at 7:30 a.m. stated, He often refuses his tube feeding and will not let them turn it on all of the time. The medical record did not contain evidence the resident often refused his tube feeding, or would not allow it to be turned on. Review of the abuse/neglect files, revealed on 11/17/13 Resident #1 was found with his tube feeding covering the entirety of the underside of the resident and his bed. The enteral feeding record for 11/17/13 was reviewed. It indicated his feeding was administered as ordered. There was nothing in the record which indicated the resident did not receive the tube feeding because it had leaked onto the resident and onto his bed. The enteral feeding sheet for November 2013 stated he was to receive 720 ml at the rate of 45 ml per hour. This did not occur on 11/17/13; however, the record reflected the resident received the tube feeding as ordered. The director of nursing (DON) was interviewed, on 03/20/14 at 2:00 p.m., regarding the facility's process for making sure residents received tube feedings as ordered. She said the facility did not do intake and output monitoring unless it was ordered by the physician. She was asked how the the facility monitored the the amount of tube feeding formula and water was administered each day, and how they knew residents received the amount as ordered. The DON said they did not utilize the administration pump to monitor the amount of feeding administered. She said it was just the facility's practice to turn it on and off at a specific time. She was made aware of the two (2) occasions identified when the resident did not receive his feeding as ordered, and the fact staff said at times the resident would not allow the tube feeding to be turned on. The DON said the facility did not have an accurate account of the amount of intake the resident received daily. She stated if he did not get the feeding, the nurses should document this at the time he refused it.",2017-03-01
7664,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,520,F,1,0,OP4H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the quality assessment and assurance committee (QAA) failed to develop a plan of action to correct a quality deficiency of which the facility was aware. The QAA committee failed to develop and implement a plan to ensure the environment was as free of accident hazards as possible. Unlocked and unattended medication carts had been identified by the facility prior to the survey. At the time of the survey, an unlocked and unattended medication cart was observed on the North unit, where residents were observed in the vicinity. This had the potential to affect more than an isolated number of residents on the North Unit. North Unit Census: 49. Facility Census: 125. Findings include: a) Medication Cart On 03/25/14 at 4:13 p.m., on the North unit beside of room [ROOM NUMBER], a medication cart was observed unattended in the hallway. Observation revealed it was also unlocked. The medication cart was continually observed for three (3) minutes, from 4:13 p.m. until 4:16 p.m. There were multiple residents observed in the hall walking past the cart. At 4:16 p.m. on 03/25/14, licensed practical nurse (Employee #140) came down the hall from the nurses' station. She was made aware her cart was left unlocked and unsupervised in the hall. Employee #140 stated she was aware she should not leave the cart unlocked, but she had an emergency. The director of nursing (Employee #2) was made aware of the observation of the unattended and unlocked medication cart on 03/25/14 at 4:30 p.m. She stated she had just discussed the issue with the medication carts being unlocked at the last nurse's meeting.",2017-03-01
7665,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-28,315,D,1,0,QQWV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure three (3) of nine (9) sample residents received appropriate services to prevent urinary tract infections (UTIs). Resident #1, for whom there was no evidence of a catheter change for five (5) months, was observed with sediment in the catheter tubing and the urine in the drainage bag was dark and cloudy, indicating a potential UTI. In addition, proper hygiene measures were not implemented when providing incontinence care to Resident #51 and Resident #119 to prevent a urinary tract infections. Resident identifiers: #1, # 51, and #119. Facility Census: 125. Findings include: a) Resident #1 During an observation of Resident #1's dressing changes, at 9:40 a.m. 03/20/14, it was noted this resident had an indwelling catheter present. The tubing from the catheter to the drainage bag had a large amount of sediment. The urine in the catheter drainage bag was dark and very cloudy. When Employee #130 (Registered Nurse) was asked about the catheter, she agreed the urine was cloudy and the tubing contained sediment. The nurse was questioned how often the catheter was changed for the resident. She verified in the medical record the catheter was only changed as needed. The nurse phoned the physician at that time and obtained an order to obtain a urinalysis (UA) due to the cloudy urine. The urinalysis was completed and the indwelling catheter was changed on 03/20/14. The medical record was reviewed to determine when this catheter was last changed. The director of nursing (DON) verified, on 03/20/14 at 3:00 p.m., the last time it was changed was 10/14/13 (more than five (5) months ago). It was recorded on 10/18/13 the #16 french Foley catheter was changed, cloudy yellow urine obtained for urinalysis culture and sensitivity. The resident was afebrile at that time. The resident's laboratory data, on 10/14/14, indicated the resident had a UTI at that time. He had just recently completed antibiotics. The care plan for this resident identified he was at risk for complications related to his indwelling catheter due to his impaired skin integrity and history of [MEDICAL CONDITION]. The care plan goal stated his Foley catheter would remain patent over the next review period. The interventions stated change Foley catheter when dysfunction or PRN (as needed). It was not clear when PRN (as needed) would be. The interventions stated to observe (Resident #1) for s/s (signs and symptoms) of a probable UTI (urinary tract infection) such as : fever, decreased urinary output, foul smelling urine, sediment or blood in urine, decreased LOC (level of consciousness) or increased behaviors etc & report. There was no evidence the facility identified the cloudy urine or the sediment in the tubing or reported this to the physician prior to the observation during the survey on 03/20/14. b) Resident # 51 Employee #93 was observed making her final rounds prior to the end of her shift at 7:10 a.m. on 03/20/14. She was observed performing incontinence care on Resident #51. Employee #93 was observed to cleanse the resident's outer skin folds by the top of her legs wiping gently with peri-lotion. She did not attempt to cleanse the inner skin folds or separate or clean the inner labia area. c) Resident # 119 Nurse aide (NA), Employee #93 was observed at 7:40 a.m. on 03/20/14 while providing peri-care for Resident #119. She was observed to gently cleanse the resident's outer skin folds by the top of her legs, wiping gently with peri-lotion. She did not attempt to cleanse the inner skin folds or separate or clean the inner labia area. Employee #107, NA, assisted Employee #93 by holding the resident on her side while Employee #93 cleansed her. When the resident was turned to her side, she had feces on her and had a bowel movement on the bed. While Employee #107 held the resident on her side, Employee #93 cleaned the feces from the resident by wiping from the anal area toward the front, toward the urethra. By wiping from front to back, bacteria from the anal area can be transferred to the urethra, creating a potential to cause urinary tract infections. The director of nursing (Employee #2) was made aware of the observations regarding the improper technique for peri-care observed for Residents #51 and #119 on 03/20/14 at 4:00 p.m.",2017-03-01
7860,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,160,D,0,1,ZN3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident fund accounts, review of the facility's resident funds policy, and staff interview, the facility failed to convey a resident's personal fund to the individual administering the resident's estate within thirty (30) days of death. One (1) of five (5) resident fund accounts reviewed contained this error. Resident identifier: #64. Facility Census: 124. Findings include: a) Resident # 64 An interview was conducted with Employee # 93, the office manager, at 1:00 p.m. on [DATE]. She stated when a resident expired the money in their account was disbursed to the appropriate person within thirty (30) days of death. Final accounting for Resident #64's resident fund account was reviewed at 2:00 p.m. on [DATE]. The review revealed Resident #64 expired on [DATE]. The balance of Resident #64's personal fund account on [DATE] was $2793.07. The facility's resident funds policy states, Disbursement of monies will be done in accordance with state regulations. An interview was conducted with Employee #19, the facility bookkeeper, at 9:00 a.m. on [DATE]. Employee #19 reported they had missed this and had not sent the disbursement of the money to Resident #64's son. She reported they were in the process of doing it, but she was aware it had been longer than thirty (30) days since the resident's death.",2017-01-01
7861,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,166,E,0,1,ZN3T11,"Based on review of the facility's Record of Customer and Family Concern forms, review of reportable incidents, staff interview, and resident interview, the facility failed to resolve and/or failed to ensure prompt efforts to resolve grievances in regard to misappropriation of resident property. The facility was aware of numerous complaints of missing money and/or property. There was no evidence the facility was working toward a resolution regarding this known problem. The grievances of thirteen (13) residents, from the past year, had no resolution and/or no evidence the facility was actively working toward a solution for concerns of misappropriation of resident property. Resident identifiers: #237, #168, #91, #71, #7, #95, #56, #62, #138, #64, #170, #18, and #11. Facility Census: 124. Findings include: a) Resident #237 Review of the facility's reportable incidents, on 01/09/13, revealed on 03/10/12, Resident #237 reported he was missing $11.00. The facility completed an investigation which found no one had seen any money belonging to this resident. The corrective action taken by the facility was reimbursement of the resident's money and the facility provided the resident a lock box for his room. b) Resident #168 Review of a Record of Customer and Family Concern form, dated 10/22/12, revealed Resident #168's laptop was missing. The facility made attempts to contact the resident's family in order to replace the laptop. However, there was no evidence to suggest the facility had conducted an investigation to determine what had happened to the laptop. c) Resident #91 Review of the facility's reportable incidents, conducted on 01/09/13, revealed on 08/14/12, Resident #91 reported $50.00 was missing from his/her room. The facility's investigation revealed no one reported seeing any money belonging to the resident. The corrective action taken by the facility was reimbursement of the resident's money and the facility installed a lock box in the resident's room. d) Resident #71 A review of the facility reportable incidents, conducted on 01/09/13, revealed on 10/09/12, Resident #71 reported she was missing $45.00. After completion of the investigation, the facility could not substantiate any misappropriation of resident funds. The corrective action taken by the facility was education of the resident to not have large amounts of money in her room and to utilize her lock box which had been provided by the facility. Resident #71's money was not reimbursed. e) Resident #7 Review of the facility reportable incidents, conducted on 01/09/13, revealed on 12/09/12, Resident #7's family reported she was missing $25.00. The facility's investigation revealed no one reported seeing any money belonging to the resident being removed from her room. The corrective action taken by the facility was reimbursement of the resident's money and the facility encouraged the resident's family to keep money in the resident fund account instead of the resident's room. f) Resident #95 A review of the facility's reportable incidents, conducted on 01/09/13, revealed on 04/27/12, Resident #95 reported she was missing $50.00 from her change purse. The resident reported she had seen the $50.00 the morning of 04/27/12 and around 4:00 p.m. the same day the money was missing. The facility's investigation revealed no one reported seeing any unusual activity or unusual people entering the resident's room or going through her belongings. The corrective action taken by the facility was encouraging the resident to use the lock box which had been in the resident's room for a lengthy period of time. This resident's money was not reimbursed. During the resident council president interview, on 01/10/13 at 1:30 p.m., Resident #95 (resident council president) revealed missing items and reimbursement for missing/stolen money was an issue residents felt had not been resolved by the facility. g) Resident #56 Review of the facility reportable incidents, conducted on 01/09/13, revealed on 05/26/12, Resident #56 reported missing money from his wallet. The facility's investigation revealed no one had seen any money belonging to this resident, and the resident did not see anyone take the money from his wallet. The corrective action taken by the facility was to educate the resident to lock all money in his lock box and put the key away while sleeping. The facility reimbursed this resident's money. h) Resident #62 A review of the facility's reportable incidents, conducted on 01/09/13, revealed on 03/08/12, the resident reported while she was in the front lobby of the building, her money was stolen from her change purse that was in the top drawer of her night stand beside the bed. The facility's investigation revealed no one had seen any money belonging to this resident. The resident did not know how much money she had lost, and had given the facility staff two (2) different amounts. The resident also did not witness anyone take her money. The corrective action taken by the facility was to educate the resident to lock all money in the lock box in her room. This resident did not have her money reimbursed. i) Resident #138 Review of the facility's reportable incidents, conducted on 01/09/13, revealed on 05/28/12, Resident #138 reported missing money from her room. The resident reported she last saw the money on 05/25/12. The facility's investigation revealed that no one reported seeing any money belonging to this resident. The facility's corrective action was to reimburse the missing money and provide the resident with a lock box for her room. They educated the resident to lock all her money in the lock box. j) Resident #64 Review of the facility's reportable incidents, conducted on 01/09/13, revealed on 06/01/12, Resident #64 reported she was missing $10 from her lock box. The resident reported the last time she saw the money was 05/30/12. The facility's investigation revealed no one reported seeing any money belonging to this resident. The corrective action taken by the facility was to reimburse the resident's money and offered to keep the key to the lock box locked on the medication cart. They also educated the resident to keep her key in a safe place. k) Resident #170 Review of the facility's reportable incidents, conducted on 01/09/13, revealed on 11/20/12, Resident #70 reported his laptop was missing. The facility's investigation revealed the resident reported a nurse came in and told him she would lock up his computer. The resident was unable to give a description of the nurse. The facility found no one removed the laptop from the resident's room and no one recalled having seen anyone unusual entering the resident's room. The facility was unable to substantiate any employee misappropriated the resident's property. Corrective action taken by the facility was to replace the resident's laptop. Staff interview with the Nursing Home Administrator (NHA) revealed the facility had not yet replaced the laptop, but offered the resident and family the option of replacement. l) At 8:40 a.m. on 01/10/13, an interview was conducted with the NHA. The NHA reported missing money was reimbursed on a case by case basis. She reported the typical practice was, if a resident had a lock box in their room when the money became missing, they would not be reimbursed the missing money; however, if the resident did not have a lock box in their room when the money became missing, the resident was reimbursed the missing the money. The NHA reported residents were educated about the lock box, and their responsibility to keep up with the key to ensure their money was safe. She also stated lock boxes were not appropriate for everyone because of certain cognitive impairments. This practice was not consistently implemented, as evidenced by some residents had their money reimbursed even though they had a lock box already in place, while others did not have their money reimbursed because they had a lock box. m) Resident #18 During an interview with Resident #18, on 01/8/13 at 8:46 a.m., she described three (3) occasions where her personal property was missing, twice with no resolution. The first occurrence resulted in her missing $10. She stated the facility reimbursed the money and she was satisfied with the resolution. The second occurrence was a few months ago and she had $20 come up missing. She said she went to the main woman in charge and was told her own grandson must have taken the money. The resident stated this offended her. She stated her grandson comes to visit and she unlocks her lock box and lets him take the quarters she wins at bingo. She said at no time did her grandson have access to her lock box alone. Resident #18 said she is right beside him when she gives him her quarters. A reportable incident form, regarding the missing $20 was provided by the facility and reviewed. The resolution was to provide her with a lock box, which she refused. This was inconsistent with the information provided by Resident #18. She described having a lock box at the time the money was missing. The third occurrence wa a few weeks after the $20 was stolen. Resident #18 stated she had a bowl of chocolates by her television, and some quarters on her over-the-bed table, all which came up missing. She said she found two (2) quarters on the floor of her bathroom the next morning. She did not report this, as she was discouraged by the manner the facility handled her missing property previously. She stated she did not feel it would benefit her to make a report. n) Resident #11 During Stage one of the Quality Indicator Survey (QIS), the resident was interviewed on 01/08/13 at 10:27 a.m. The resident said she had $200.00 stolen from her locked box in the room. The resident stated she kept her key to the box in a blue change purse under her pillow. She stated she assumed someone took the key while she was out of the room, or perhaps while she was sleeping. She stated the money was a gift from her children given to her for birthdays and Christmas and she intended to use the money to purchase a new pair of glasses. The resident said one day her daughter came to take her out of the facility and when she went to get her money, it was missing. She said she reported the incident but could not recall the exact date. When asked about the facility's resolution to her allegation she stated she did not know what happened. Review of a social services assessment, completed on 11/19/12, found the resident's brief interview of mental status (BIMS) score was 13.0 which indicated the resident was cognitively intact. The facility's reportable allegations of abuse/neglect/and misappropriation of personal property were reviewed. This revealed the resident had reported she was missing $200.00 from her lock box in her room on 11/06/12. The incident of the missing money was reported to the proper state authorities by the facility on 11/06/12. Review of the five-day follow up report found the outcome/results of the investigation were, Per resident and MPOA (medical power of attorney) report, resident had money in her lock box and she had the key hidden. Interviews and witness statements confirmed this. Resident was offered to keep key in nurse's cart but refuses. The administrator was interviewed on 01/09/13 at 2:00 p.m. She stated the facility did not replace the resident's money because the resident was provided a locked box and was responsible for the safekeeping of her funds.",2017-01-01
7862,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,225,D,0,1,ZN3T11,"Based on review of the facility's Record of Customer and Family Concerns file, review of reported allegations of resident abuse/neglect, and staff interview, the facility failed to report all allegations of resident abuse/neglect to State agencies as required. The facility failed to report a missing laptop computer, an allegation of misappropriation of resident property, to State agencies as required. Resident identifier: #168. Facility Census: 124. Findings Include: a) Resident #168 Review of a Record of Customer and Family Concerns form, dated 10/22/12, revealed Resident #168's laptop computer was missing. The facility's reportable allegations were reviewed. There was no evidence this allegation of misappropriation of resident property was reported to the appropriate State agencies, i.e., the Office of Health Facility and Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Ombudsman. An interview was conducted, at 3:40 p.m. on 01/15/13, with the Nursing Home Administrator (NHA). She confirmed this allegation had not been reported to the appropriate State agencies. She also confirmed this was an allegation of misappropriation of resident property and it should have been reported to appropriate State agencies.",2017-01-01
7863,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,244,E,0,1,ZN3T11,"Based on review of resident council minutes, staff interview, and the resident council president interview, the facility failed to act upon and/or attempt resolutions for concerns of the resident council. There was no evidence the facility seriously considered the group's recommendations and attempted to accommodate those recommendations. Additionally, there was no evidence the facility communicated its decisions regarding recommendations to the resident council. This practice had the potential to affect more than a minimal number of residents. Facility census: 124. Findings include: a) During the resident council president interview, on 01/10/13 at 1:30 p.m., Resident #95, the resident council president, identified issues residents felt had not been resolved. These issues included: missing items, complaints regarding nurse aides, the smoking policy, and reimbursement of missing/stolen money. Resident #95 verbalized the consensus of the resident council was the facility failed to listen to the views and act upon the grievances and recommendations of the resident council. According to Resident #95, Employee #34 (director-recreation) was the designated staff person responsible for assisting the resident council. He stated other staff members could attend the meeting if requested by the council. Resident #95 said those requests for administrative staff to attend meetings fell on deaf ears. Additionally, Resident #95 stated the facility did not attempt to accommodate the recommendations of the resident council. She also said the facility did not clearly communicate its decisions to the council. Review of resident council minutes for the past six (6) months confirmed some issues revealed during Resident #95's interview. In August 2012, the council requested department heads to attend monthly meetings. The facility's resolution was to divide department heads to alternate attendance at the resident council, and the council could request additional attendance for issues to discuss. October 2012 was the only month in which a department head attended. Minutes of the December 2012 meeting revealed the council requested a minimum of one (1) department head at every meeting. The resolution for this request was, Will have guest services director plus assign one (1) additional department head to attend meeting each month. Will verify attendance with Recreation Director. Staff interview, on 01/14/13 at 3:00 p.m., with Employee #34 (the recreation director) revealed she felt this was the opinion of the resident council president - that issues were not addressed. However, Employee #34 could offer no evidence of attempts to address the issues such as staffing, the smoking policy, and the storage of residents' personal belongings.",2017-01-01
7864,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,253,E,0,1,ZN3T11,"Based on observation and staff interview, it was found the facility had not ensured the environment in resident rooms was kept in a manner that was sanitary and in good repair. Door facings of resident bathrooms were scuffed and scratched, the plaster in resident rooms was cracked and missing and not easily cleanable, the grout in one resident shower was blackened, and a privacy curtain was soiled. This was found during random observations of seven (7) resident rooms on the south hall of the facility. Rooms 212, 308, 306, 318, 221, 321, and 300. Facility census: 124. Findings include: a) Observation with the environmental services supervisor, Employee #17, at 2:30 p.m. on 01/14/13, found the following issues in resident rooms: 1) Room 212 The plaster was cracked and scuffed on the wall beside the window at bed B. 2) Room 308 Black markings were on the wall and a brown substance was spattered on the wall beside the doorway. The light fixtures above both beds had been removed and replaced with smaller fixtures which left holes in the plaster. 3) Room 306 Several spots on the walls had been plastered but not painted. 4) Room 318 There were deep scrapes and scratches on the door facings leading to the bathroom 5) Room 221 The plaster was cracked and missing in the resident's bathroom shower stall. The floor tiles in the shower area had a black substance on the grout around the tiles near the floor area. 6) Room 321 The door facings, leading to the bathroom were scuffed and scratched. b) Room 300 Observation with the director of nursing, Employee #5, on 01/15/13 at 2:30 p.m. found the privacy curtains were not hooked at both bed A and bed B. The curtain around bed A was stained with a brown substance, which appeared to be feces.",2017-01-01
7865,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,279,D,0,1,ZN3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan reflective of the care and diet provided to a [MEDICAL TREATMENT] resident and the care provided to a resident with a skin tear. This was true for two (2) of twenty-eight (28) sample residents reviewed in Stage II of the Quality Indicator Survey (QIS). Resident identifiers: #125 and #17. Facility census: 124. Findings include: a) Resident #125 Review of the resident's care plan, created on 10/30/09, found a problem: (Name of resident) is at risk for impaired renal function as well as complications related to his [MEDICAL TREATMENT] of [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) requiring [MEDICAL TREATMENT] three times a week. Two goals were associated with this problem: (Name of resident) [MEDICAL TREATMENT] access will remain patent over the upcoming review period and (Name of resident) will remain free of complications from [MEDICAL TREATMENT] through the next review. The approaches were: 1. Administer medications before leaving for [MEDICAL TREATMENT] and or after returning from [MEDICAL TREATMENT] as ordered per physician. 2. Dietary to send a snack with resident to [MEDICAL TREATMENT]. 3. [MEDICATION NAME] to be administered before [MEDICAL TREATMENT] on Monday, Wednesday and Friday per physician at [MEDICAL TREATMENT] center, give before [MEDICAL TREATMENT] due to increased [MEDICAL CONDITION]. 4. Observe residents permacath located to AV (artery vein) graft to left forearm every shift for signs and symptoms of infection and or complications regarding its placement. 5. Request pre and post weights from [MEDICAL TREATMENT] center; may use [MEDICAL TREATMENT] weights as patient refuses weights to be obtained in facility. 6. Transfer to (Name of [MEDICAL TREATMENT] center) with telephone number address and treatment time. Send [MEDICAL TREATMENT] communication book with resident. An interview with the resident, at 1:30 p.m. on 01/10/13 confirmed the facility does not send a snack with him to [MEDICAL TREATMENT] and he does not want a snack. He stated he did not want to eat while at [MEDICAL TREATMENT] because it would make him sick. An interview was conducted with Employee #12, the chef manager, at 1:40 p.m. on 01/10/13. Employee #12 stated, We don't have any order to send food with the resident, if he wanted food we would send it. I think he eats before he leaves. At 1:45 p.m. on 01/10/13 the director of nursing (DON), Employee #5, confirmed the care plan was incorrect and she stated she would update the care plan. On 01/11/13 at 1:45 p.m., the DON verified the resident did not have a permacath as documented in the care plan approach. She stated she would correct the care plan to address the AV graft to the left upper arm. At 10:00 a.m. on 01/14/13 at 10:00 a.m., the DON confirmed the facility did not have a physician's orders [REDACTED]. The DON stated she obtained the following physician's orders [REDACTED]. (left) upper arm graft for bruit and thrill q (every shift.) She was unable to provide evidence the AV graft was checked/observed every shift prior to 01/10/13. Further review of the care plan, which was created on 10/30/12 by the dietitian, found the problem: Resident is of nutrition concern d/t (due to) multiple diagnosis ([MEDICAL CONDITION] on [MEDICAL TREATMENT]). An approach to this problem was: Provide diet as ordered. Review of the medical record found a physician's orders [REDACTED]. No orange juice and large portion of protein with all meals. The resident's care plan was discussed with Employee #32, the dietary manager, at 11:28 a.m. on 1/14/13. She agreed the care plan failed to address the resident's specific diet order and stated she would get the dietitian to discuss the diet. Employee #158, the registered dietitian, was interviewed at 11:48 a.m. on 01/14/13. She stated the care plan did not need to be specific. Regulations require residents' care plans be measurable, comprehensive and describe services being provided. All residents, receiving food by mouth, would be provided a diet as ordered. The care plan was not specific regarding this resident's specific therapeutic diet prescribed by the physician. b) Resident # 17 Medical record review, at 11:17 a.m. on 01/10/13, revealed the resident had a change in condition related to a skin tear on 12/27/12. The medical record revealed there was an order to, Cleanse skin tears to the left hand. Pat dry. Apply dermagel and wrap with kling change Q (every) 5 days and as needed. The order start date was 12/27/12. The treatment administration record (TAR) was reviewed for Resident #17 on 01/14/13. The TAR revealed the resident's treatment was completed every five (5) days since the order was written on 12/27/12. The care plan for Resident # 17 was reviewed at 10:20 a.m. on 01/14/13. The care plan did not contain a care plan for the resident's skin tear. Observation of Resident #17, at 10:00 a.m. on 01/15/13, revealed the resident had a bandage on his left hand. Employee #130 was interviewed at 10:15 a.m. on 01/15/13. She reported the bandage on the resident's hand was because of the skin tear to his left hand. She reported it was not healed and still required a bandage. Interview with Employee #143, at 11:00 a.m. on 01/15/13, revealed the resident did not have a care plan for his current skin tear. Employee #143 reported the resident had an old care plan for a skin tear but not for the current skin tear. Staff interview with Employee #5, the director of nursing (DON) at 12:50 p.m. on 01/15/13, revealed she could not locate a current care plan for Resident # 17's skin tear.",2017-01-01
7866,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,309,D,0,1,ZN3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident who received [MEDICAL TREATMENT] was provided necessary care and services. The facility did not follow their policy for care of a resident receiving [MEDICAL TREATMENT], resulting in a failure to assess the resident daily and upon return from the [MEDICAL TREATMENT] center; a failure to ensure communication was maintained with the [MEDICAL TREATMENT] center; and a failure to develop a care plan which addressed how information would be exchanged with the [MEDICAL TREATMENT] center, including information related to nutritional status and care of the arteriovenous (artery vein) (AV) graft. This was true for one (1) of one (1) resident who received [MEDICAL TREATMENT], in a facility sample of twenty-eight residents, who were reviewed in Stage II of the quality indicator survey (QIS). Resident identifier: #125. Facility census: 124. Findings include: a) Resident #125 Review of the medical record found the resident was receiving [MEDICAL TREATMENT] on Monday, Wednesday and Friday at an offsite [MEDICAL TREATMENT] center for end stage [MEDICAL CONDITION] ([MEDICAL CONDITION].) Review of the current care plan, created on 10/30/09, found a problem: Impaired renal function as well as complications related to [DIAGNOSES REDACTED]. An approach associated with this problem was, Request pre and post weights from [MEDICAL TREATMENT] center; may use [MEDICAL TREATMENT] weights as patient refuses weights to be obtained in the facility. An interview with the director of nursing (DON), Employee #5, on 01/10/13 at 1:45 p.m., found the facility had no record of the resident's weights before and after [MEDICAL TREATMENT]. The DON stated, The [MEDICAL TREATMENT] center has never sent us any weights. Further review of the resident's medical record found a facility form entitled, Weekly [MEDICAL TREATMENT] Evaluation Tool. The form required completion of pre and post-[MEDICAL TREATMENT] information which included: assessing the resident's level of consciousness (LOC), assessment of bruit and thrill, condition of dressing covering the access cite, vital signs and any other signs and symptoms. The weekly [MEDICAL TREATMENT] evaluation tool was reviewed for the period of 11/02/12 through 12/28/12. Omissions in documentation were found on the following days on which the resident attended [MEDICAL TREATMENT]: -11/02/12 no documentation of bruit and thrill pre and post-[MEDICAL TREATMENT], no documentation of the dressing post-[MEDICAL TREATMENT] and no vital signs pre-[MEDICAL TREATMENT]. -11/05/12 no documentation of bruit and thrill pre and post-[MEDICAL TREATMENT], no documentation of dressing post-[MEDICAL TREATMENT] and no documentation of vital signs pre-[MEDICAL TREATMENT]. -11/12/12 no documentation of bruit and thrill pre and post-[MEDICAL TREATMENT], no documentation of dressing post-[MEDICAL TREATMENT]. -11/13/12 no documentation of bruit and thrill pre and post-[MEDICAL TREATMENT]. -11/16/12 no documentation of bruit and thrill pre-[MEDICAL TREATMENT] and no documentation of any vital signs pre-[MEDICAL TREATMENT]. -11/23/12 no documentation of resident's LOC, bruit and thrill, dressing or vital signs post-[MEDICAL TREATMENT]. -11/28/12 no documentation of vital signs pre-[MEDICAL TREATMENT] and no documentation of resident's LOC, bruit and thrill, dressing and vital signs post-[MEDICAL TREATMENT]. -12/05/12, no documentation of the bruit and thrill for pre and post-[MEDICAL TREATMENT]. -12/10/12, no documentation of bruit and thrill pre and post-[MEDICAL TREATMENT] and no documentation of the resident's vital signs pre-[MEDICAL TREATMENT]. -12/17/12 no documentation of bruit and thrill pre and post-[MEDICAL TREATMENT], and no documentation of vital signs pre-[MEDICAL TREATMENT]. -12/19/12 no documentation of bruit and thrill, post-[MEDICAL TREATMENT]. -12/26/12 no documentation of bruit and thrill pre and post-[MEDICAL TREATMENT] and no documentation of vital signs pre-[MEDICAL TREATMENT]. -12/28/12 no documentation of bruit and thrill pre and post-[MEDICAL TREATMENT] and no documentation of residents LOC pre-[MEDICAL TREATMENT]. The DON was interviewed on 01/10/13 at 1:45 p.m. She confirmed it was expected the pre and post-[MEDICAL TREATMENT] evaluation tool was to be completed by facility nursing staff on the days the resident attended [MEDICAL TREATMENT]. She stated it was expected the nurse on duty would assess the bruit and thrill both pre and post-[MEDICAL TREATMENT], complete vital signs pre and post-[MEDICAL TREATMENT], assess the resident's LOC pre and post-[MEDICAL TREATMENT], and address the condition of the dressing on post-[MEDICAL TREATMENT] only. She added the resident would not have a dressing pre-[MEDICAL TREATMENT]. She was unable to produce evidence the required information for assessing the resident pre and post-[MEDICAL TREATMENT] was completed as required. Further review of the care plan, found an approach initiated on 10/30/09, Dietary to send a snack with resident to [MEDICAL TREATMENT]. An interview with the resident at 1:30 p.m. on 01/10/13 confirmed the facility does not send a snack with him to [MEDICAL TREATMENT] and he does not want a snack. An interview was conducted with Employee #12, the chef manager, at 1:40 p.m. on 01/10/13. Employee #12 stated, We don't have any order to send food with the resident, if he wanted food we would send it. I think he eats before he leaves. At 1:45 p.m. on 01/10/13 the DON confirmed the care plan was incorrect and she stated she would update the care plan. Another approach addressing the problem of [MEDICAL TREATMENT] was, Observe (Name of resident) permacath located to AV (artery vein) graft to LFA (left forearm) q (every) shift of s/s (signs and symptoms) of infection and or complications regarding its placement. On 01/11/13 at 1:45 p.m., the DON verified the resident did not have a permacath and she stated she would correct the care plan to address the AV graft to the left upper arm. Review of the facility's policy for [MEDICAL TREATMENT]: graft and fistula care, found the following: Policy: Patients who receive [MEDICAL TREATMENT] treatments through graft or fistula will be monitored for complications. Process: -1. Verify any specific care orders or instructions form attending physician or [MEDICAL TREATMENT] center. -2. Perform routine observation of access site daily and on return from [MEDICAL TREATMENT] center. Observe for signs of complications including but not limited to: 2.1 Pain, swelling, redness, odor, hardness, bleeding or drainage at site; 2.2 Color, temperature of extremity; 2.3 Presence of pain or numbness in extremity; 2.4 Pulses distal to access site (fistula/graft); 2.5 Presence of bruit on auscultation with stethoscope; 2.6 Presence of thrill (vibration) by pa;palpation Section 10 of the policy also required documentation of the above information. Interview with the DON, at 10:00 a.m. on 1/14/13, found she would expect the nursing staff to check the bruit and thrill before and after [MEDICAL TREATMENT] and she would have expected staff to take vital signs before the resident left for [MEDICAL TREATMENT] and after return from [MEDICAL TREATMENT]. The DON stated, We just got an order from the physician to check bruit and thrill. The DON provided a copy of the physician's orders [REDACTED]. Check lt. (left) upper arm graft for bruit and thrill q (every) shift. The DON, when interviewed on 01/14/13 at 10:00 a.m., was unable to provide evidence nursing staff observed the access site daily and upon return from the [MEDICAL TREATMENT] center as required by the policy before 01/10/13.",2017-01-01
7867,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,329,D,0,1,ZN3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of medication maximum dosage recommendations, the facility failed to ensure the medication regimen for one (1) of ten (10) residents reviewed for unnecessary medications was free from the potential for an excessive dose. The resident's orders for Tylenol ([MEDICATION NAME] ) created a potential for the resident to receive this medication in an amount greater than the manufacturer's safe daily maximum recommended dose, which is 3000 mg in a 24 hour period. Resident identifier: #226. Facility census: 124. Findings include: a) Resident #226 Resident #226's medical record, which was reviewed on 01/14/13, showed the resident had orders for [MEDICATION NAME] 20.3 ml by mouth every four (4) hours for fever greater than 38.3 degrees Celsius. This equals 650 milligrams of [MEDICATION NAME] every four (4) hours. This order created a potential for the administration of 3900 mg of [MEDICATION NAME] in a 24 hour period. The daily safe maximum dosage, as indicated by the manufacturer of Tylenol, is 3000 mg of [MEDICATION NAME] in a 24 hour period. In addition, the resident also had an order for [REDACTED]. If given all possible doses of the two (2) orders for medications containing [MEDICATION NAME], the resident had the potential to receive 5200 mg of [MEDICATION NAME] in a 24 hour period. An interview with Employee #5, the director of nursing (DON) on 01/14/13, at approximately 4:15 p.m., verified this finding. After this discussion, the DON wrote an order to discontinue the [MEDICATION NAME] for fever.",2017-01-01
7868,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,356,C,0,1,ZN3T11,"Based on observation and staff interview, the facility failed to post the nurse staffing information regarding available direct care staff daily, as required by this regulation. The data observed posted was four (4) days prior to the date of the observation. This practice had the potential to affect all residents. Facility census: 124. Findings include: a) Observation, on 01/08/13, of the nurse staffing data, which must be posted daily by the facility, found it was not current. The date on the posting was 01/04/13. 01/08/13 at 10:00 a.m., Employee #5 (director of nursing) confirmed that it was not correct and stated she would get it corrected.",2017-01-01
7869,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,364,F,0,1,ZN3T11,"Based on observation, taste test evaluation, and staff interview, it was determined the facility failed to ensure food was held for service in a manner which conserved nutritive value and food quality. Prepared food items were observed on the steam table for more than one (1) hour before service to the residents began. This had the potential to compromise the nutritive value, as well as the quality, of the food items. Additionally, the facility failed to ensure pureed foods were well seasoned and flavorful. These practices had the potential to affect all residents who were served food prepared and distributed from this central location. Facility census: 124. Findings include: a) When performing meal observations of the evening meal on 01/08/13, pans of food for dinner were observed already on the steam table at 4:30 p.m. Observation revealed the service of these food items did not begin until 5:35 p.m. This excessive length of holding time on the steam table had the potential to compromise the nutritive value, as well as the quality, of the food items. b) Foods were test tasted at the time of the observation of the evening meal. The pureed food items tasted bland and lacked seasoning to enhance the taste. This was discussed with the administrator and dietary manager on 01/09/13 in the afternoon.",2017-01-01
7870,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,371,F,0,1,ZN3T11,"Based on staff interview and observation, the facility failed to ensure foods were stored, prepared, distributed, and served under sanitary conditions. Food items were uncovered, unlabeled, and undated. In addition, pans were stored stacked inside each other prior to air drying. The trapped moisture created a medium for bacterial growth. These practices had the potential to affect all residents who received nutrition and hydration services from the dietary department. Facility census: 124. Findings include: a) Observation of the noon meal on 01/07/13, on the North hall, revealed juice containers were left uncovered on the service cart. The juice containers were not dated or labeled with an expiration date or the type of juice. During an interview, on 01/07/13 at 12:50 P.M., with Employee #78, a licensed practical nurse, she acknowledged the juices should be covered. She then covered the juices with plastic wrap that was on the service cart. b) During lunch, on 01/07/13, a cart was observed on the South Hall with one (1) gallon each of white milk, chocolate milk, and water. There were no caps or coverings over the openings to protect the food products from potential contamination. In addition, there were no dates reflecting when the products were opened and/or when they should be discarded. There was also a container of thickened milk with a tab-top lid that was opened and remained opened. At 1:00 p.m., the facility Chef Manager, Employee #12, was interviewed. He stated when the staff left the lids off, the milk was discarded. At that time, he discarded all open milk/water jugs; however, he was observed replacing the tab-top lid on the thickened milk and placed it in the refrigerator. This product had been on the unit and was open to potential contamination while on the unit. Breakfast was observed at 8:40 a.m. on 01/08/13. Again, on the South Hall, the milk and water jugs had no lids and no dates regarding opening and discarding. Supper, on 01/08/13, was observed at 6:00 p.m. on the North Hall. The milk jugs had no lids and no dates. c) Initial tour of the kitchen The initial tour of the kitchen was conducted at 11:45 a.m. on 01/07/13 with dietary Employee #12, the chef manager, and Employee #32, the food service director. Opened pepperoni was noted in a plastic container with no date. In addition, ranch salad dressing was poured into plastic cups which had no date. Further observation of the kitchen with Employee #12, at 11:55 p.m. on 01/07/13, found eight (8) metal pans used to store food on the steam table stacked together. These pans contained trapped moisture which created a potential for bacterial growth. d) South pantry Observation of the resident's pantry refrigerator at 1:30 p.m. on 01/09/13, with Employee #32, the food service director, found an unidentified carafe of red liquid dated 07/01/12. Employee #32 identified the liquid as punch. e) When performing the dietary tour prior to lunch time on 01/08/13, pans were again found stacked and stored wet, with water trapped between. This allowed for the potential of bacteria to grow in a dark, moist environment. The dietary manager was present when this was noted and verified the issue.",2017-01-01
7871,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,431,E,0,1,ZN3T11,"Based on observation, staff interview, review of the facility's nursing drug handbook, and review of medication manufacturer's information, the facility failed to ensure safe and secure storage of medications, and failed to ensure opened medications were dated and/or labeled so unused portions were discarded in accordance with manufacturers' specifications. Four (4) of the facility's six (6) medication carts contained opened vials of insulin which were not dated or labeled to indicate when the vials were opened. In addition, a treatment cart, which contained prescription medications for treatments, was not secured to prevent unauthorized access to medications. The cart was observed unlocked and unattended. These practices had the potential to affect more than a limited number of residents. Facility census: 124. Findings include: a) During observation of the six (6) medication carts in the facility, four (4) of the carts had open vials of insulin without a date or label indicating when the bottle was opened. The types of insulin observed were Lantus, Novolog, Levemir, and Humalog. An interview with Employee #151, a licensed practical nurse, was conducted at 12:30 p.m. on 01/09/13. She said the facility required the nurses to date insulin bottles with the date the bottle was opened. This was discussed with the administrator (NHA), on 01/09/13 at 1:00 p.m. The NHA produced information regarding pharmacy storage which stated, Once any drug or biological package is opened, follow manufacturer/supplier guidelines for in use expiration dating. On 01/10/13, a medication book titled Nursing 2012 Drug Handbook, used by the facility, was reviewed. This handbook described both Lantus and Novolog were to be discarded after the vial had been opened 28 days. It noted Levemir may be used for up to 42 days after opening. The package insert provided by the manufacturer of Humalog stated, In use Humalog vials . must be used within 28 days or be discarded, even if they still contain Humalog. This was discussed and confirmed with the Director of Nursing (DON) on 01/10/13 at 11:00 a.m. b) Observation of the treatment cart located on the south hall, at 1:30 p.m. on 01/18/13, revealed it was unattended and unlocked. The treatment cart contained prescription medications used for treatments. Employee #98, a licensed practical nurse, was in a resident's room providing a treatment when the cart was found unattended and unlocked in the hallway. When interviewed, the nurse stated she thought the cart was locked. She then checked the cart and stated the cart had two (2) locks, and she had only locked one (1) of them. These issues were discussed with the director of nursing (DON) at 11:10 a.m. on 01/15/13. No further information was provided.",2017-01-01
7872,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,441,E,0,1,ZN3T11,"Based on observation and staff interview, the facility failed to ensure an infection control program which prevented and controlled, to the extent possible, the onset and spread of infection in the South Dining Room. A soiled bed linen was observed on the floor in the food serving area. This had the potential to affect all residents who received nourishment from this dining room, which was more than an isolated number of residents. Facility census: 124. Findings include: a) During the evening meal observation, on 01/08/13 at 6:00 p.m., a soiled bed linen (a blanket or a bath blanket) was observed on the floor in the food serving area of the South Dining Room. The bed linen had yellow to tan colored spots on it. When asked about the soiled linen, the person serving the food stated he did not put it there, and continued serving the food. At the time of the observation, an interview was conducted with Employee #158, the dietitian. The dietitian verified the soiled linen should not be on the floor in the food service area. She removed the linen and placed it in the soiled linen container.",2017-01-01
7873,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,502,D,0,1,ZN3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the provision of timely laboratory (lab) testing for one (1) of ten (10) residents reviewed regarding medications and associated lab values. Lab tests were not obtained for this resident according to physician's orders [REDACTED].#155 Facility census: 124 Findings include: a) Resident #155 Medical record review for this resident was conducted on 01/14/13 at 3:55 p.m. This review showed the resident was ordered the following labs: an HgbA1C for diabetes every four (4) months, to be done in August 2012, December 2012 and April 2013. The medical record indicated the lab test was completed on 02/24/12, 06/08/12, 06/20/12, 07/03/12, and 10/05/12. There was no evidence the labs were completed for the months of August 2012 or December 2012 as specified in the physician's orders [REDACTED].>The BMP was ordered every six (6) months, to be completed in February 2012 and August 2012. The last BMP on the resident's record was 07/03/12. There was no evidence the resident had a BMP in August 2012, as specified in the physician's orders [REDACTED].>An interview, on 01/14/13 at 4:15 p.m., with Employee #5, the director of nursing, verified the labs had not been completed according to the physician's orders [REDACTED].#5 changed the order for the HgbA1C every four (4) months to October 2012, February 2013, and June 2013.",2017-01-01
7874,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,514,D,0,1,ZN3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure medical records were accurate. Physician orders [REDACTED]. Resident identifier: #226 and #155. Facility census: 124. Findings include: a) Resident #226 This resident's medical record was reviewed on 01/14/13 at 3:00 p.m. The resident was admitted to the facility on [DATE]. His admission orders [REDACTED]. Review of the current physician's orders [REDACTED]. Interview with Employee #5, the director of nursing (DON), on 01/14/13, verified the lab orders, written on 12/12/12, were not transcribed onto the January 2013 orders, but should have been carried forward. The DON wrote a clarification order for the lab orders, as written on 12/12/12, on the January 2013 orders. b) Resident #155 Medical record review for this resident was conducted on 01/14/13 at 3:55 p.m. This review showed the resident was ordered the following labs: an HgbA1C for diabetes every four (4) months, to be done in August 2012, December 2012, and April 2013. The medical record indicated the lab test was completed on 02/24/12, 06/08/12, 06/20/12, 07/03/12, and 10/05/12. There was no evidence the labs were completed for the months of August 2012 or December 2012 as specified in the physician's orders [REDACTED].>The BMP was ordered every six (6) months, to be completed in February 2012 and August 2012. The last BMP on the resident's record was 07/03/12. There was no evidence the resident had a BMP in August 2012, as specified in the physician's orders [REDACTED].>An interview, on 01/14/13 at 4:15 p.m., with Employee #5, the director of nursing, verified the labs had not been completed according to the physician's orders [REDACTED].#5 changed the order for the HgbA1C every four (4) months to October 2012, February 2013, and June 2013.",2017-01-01
7955,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-12-19,157,D,1,0,KHS011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and resident interview, the facility failed to ensure a resident's physician was notified of a resident's refusal of treatment. Resident #59 had physician's orders [REDACTED]. No evidence could be found to indicate the physician had been notified of the resident's refusal. One (1) of six (6) sample residents was affected. Resident identifier: #59. Facility census: 127. Findings include: a) Resident #59 On 12/18/13 at 9:30 a.m., a review of the physician orders, dated 12/05/13, found an order for [REDACTED]. A review of this resident's Medication Administration Record [REDACTED]. In an interview with Resident #59, on 12/18/13 at 10:10 a.m., this resident stated she did these flushes at home and did not like the way staff flushed her tube. On 12/18/13 at 1:30 p.m., the DON was interviewed. The DON stated she was aware Resident #59 had been doing her GJ tube flushes at home. She was also aware the flushes had not been done for thirteen (13) days. When asked if the physician had been notified of this, the DON stated No. The DON stated she would get a clarification from the physician and staff would observe Resident #59 doing the flushes.",2016-12-01
7956,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-12-19,279,D,1,0,KHS011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident observation, and staff interview, the facility failed to formulate a care plan for each resident that was based on a comprehensive assessment of the resident's needs. Resident #3 did not have a care plan addressing an enteral tube. The resident's care plan included encouraging the resident to consume fluids, although the physician had ordered nothing by mouth. Resident #3 was assessed as having no voluntary movement, but the care plan indicated the resident was to use a call light. This was found for one (1) of six (6) sample residents. Resident identifier: #3. Facility census: 127. Findings include: a) Resident #3 1) During a medical record review, on 12/18/13 at 9:00 a.m., a physician's orders [REDACTED]. Resident #3 also had a physician's orders [REDACTED].) The care plan was reviewed on 12/18/13 at 9:15 a.m. The care plan did not include focus, goals, or interventions related to the enteral feeding. The care plan, initiated on 12/13/13, indicated staff were to encourage the resident to consume all fluids during meals, although she was admitted with the NPO status. A resident observation, on 12/18/13 at 10:40 a.m., revealed the resident had an enteral tube in place. The director of nursing reviewed the care plan on 12/18/13 at 10:40 a.m. She confirmed the care plan did not address the enteral feeding. The medical record for Resident #3 was reviewed on 12/18/13 at 9:30 a.m. The initial nursing assessment indicated Resident #3 did not make even slight changes in body position by self. The care plan indicated staff were to remind Resident #3 to use the call light when attempting to ambulate or transfer. An interview with Employee #15, a nursing assistant (NA) on 12/18/13 at 10:30 a.m., and Employee #2, director of nursing (DON), on 12/18/13 at 10:45 a.m., revealed Resident #3 was immobile, required total care, and did not utilize the call bell.",2016-12-01
7957,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-12-19,309,D,1,0,KHS011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and staff interview, the facility failed to monitor a blood sugar for one (1) of two (2) residents reviewed for insulin coverage. The facility had not monitored Resident #3's blood sugar as ordered by the physician. In addition, the staff completed a treatment without a physician's orders [REDACTED]. Two (2) of three (3) residents did not receive enteral tube flushes as ordered by their physician. Resident #59 and Resident #3 did not receive the physician ordered flushes. Resident identifiers: Resident #3 and #59. Facility census: 127. Findings include: a) Resident #3 1) Resident #3's medical record was reviewed on 12/18/13 at 9:00 a.m. A physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. According to the MAR, the Accu-chek scheduled for 6:00 p.m., on 12/17/13, was omitted. Employee #112 reviewed her worksheet and acknowledged no evidence was present to indicate the blood sugar was monitored. 2) Additionally, review of the physician's orders [REDACTED]. The director of nursing (DON), Employee #2, reviewed the care plan on 12/18/13 at 10:40 a.m., and confirmed it did not address the focus, goals or interventions for the enteral feeding. The DON said a dressing was usually utilized with PEG tubes. She reviewed the medical record and treatment administration record (TAR) and confirmed an order was not present. The DON asked Employee #103 (RN) to check Resident #3's enteral tube site. The RN went to the treatment cart, obtained supplies, and entered the room. She did not look at the treatment administration record. She pulled back the resident's gown and noted a dressing was in place, dated 12/18/13. Upon inquiry, she confirmed she was not aware of a standing wound protocol related to enteral tube dressing changes. She removed the dressing, evaluated the wound, and replaced the same dressing. She then said she would have to obtain a physician's orders [REDACTED]. During another interview with the DON, on 12/18/13 at 10:45 a.m., she confirmed the treatment had been completed without a physician's orders [REDACTED].> b) Resident #59 On 12/18/13 at 9:30 a.m., a review of the physician orders, dated 12/05/13, found an order for [REDACTED]. A review of this resident's Medication Administration Record [REDACTED]. In an interview with Resident #59, on 12/18/13 at 10:10 a.m., she stated she did these flushes at home and did not like the way staff flushed her tube. On 12/18/13 at 1:30 p.m., the DON was interviewed. The DON stated she was aware Resident #59 had been doing her GJ tube flushes at home. She was also aware the resident had refused the flushes for thirteen (13) days. When asked whether the physician had been notified and whether this resident had been educated/observed doing the flushes, the DON stated No. The DON stated she would get a clarification from the physician and staff would observe Resident #59 doing the flushes.",2016-12-01
7958,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-12-19,371,E,1,0,KHS011,"Based on observation and staff interview, the facility failed to ensure food was served in a sanitary manner. During the noon meal in the South cafe, the server was observed using the same gloves to prepare food after touching her face and a number of environmental objects. This practice had the potential to affect more than a limited number of residents. Facility census: 127. Findings include: a) On 12/17/13 at 12:25 p.m., Employee #62 (dietary server), was observed serving food in the South cafe. This employee had gloves on both hands. She was observed touching her face, opening a cabinet door to retrieve bowls, and touching the food cart. Employee #62 then proceeded to retrieve a bun from the package and prepare a steak hoagie with the same contaminated gloves. In an interview with the food service director (Employee #23) and chef (Employee #122), on 12/17/13 at 12:33 p.m., they agreed Employee #62 had contaminated her gloves. They stated the server should have changed gloves each time between handling non food items and food items. They said Employee #62 would be counseled and all dietary employees would be in-serviced on the proper use of gloves during food service.",2016-12-01
7959,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-12-19,431,D,1,0,KHS011,"Based on medical record review, observation, staff interview, and facility policy and procedure review, the facility failed to ensure total parenteral nutrition (TPN) was labeled with the date and time the TPN was started, and the identity of the nurse who had hung the TPN. Additionally, the label did not indicate insulin had been added to the solution as ordered. This was found for one (1) of three (3) residents who were observed receiving intravenous therapy. Resident identifier: #59. Facility census: 127. Findings include: a) Resident #59 On 12/18/13 at 9:28 a.m., an observation of the label on Resident #59's TPN, revealed the label contained no date or time the TPN was hung, nor was there a signature of the nurse who had hung the TPN. In addition, there was no indication on the label that 30 units of insulin had been added to the TPN container as ordered by the physician. This was confirmed by a registered nurse (RN) (Employee #103). This employee agreed the label did not contain the date/time the TPN was hung, the signature of the nurse who hung the TPN, nor did it indicate that 30 units of insulin had been added to the TPN container. A review of the facility's policy and procedure titled PROCEDURE: Parenteral Nutrition: Administration of, was conducted on 12/19/13 at 10:00 a.m. In this policy, Section 11 included, Add additives as ordered. Initial additives on medication/solution container label with date, time, and nurse's initials.",2016-12-01
7960,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-12-19,441,D,1,0,KHS011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, family interview, medical record review, and policy review, the facility failed to implement an infection control program to prevent the transmission of disease/infection for three (3) of six (6) sample residents. A nurse did not utilize proper handwashing technique, a family member did not utilize transmission based precautions for a resident with Clostridium difficile, and the facility failed to follow policy and procedure for flushes of a central line. Resident identifiers: #3, #84, and #59. Facility census: 127. Findings include: a) Resident #3 During a random observation, on 12/18/13 at 10:40 a.m., Employee #103, a registered nurse (RN), completed an enteral wound assessment for Resident #3. Upon completion, she removed her gloves and washed her hands. The process lasted five (5) seconds. Upon completion of the procedure, the nurse was asked to describe the hand hygiene procedure. She said she would look it up on the computer. Specific inquiry was made to the length of time for handwashing. Again, she said she would look it up on the computer. The hand hygiene policy was reviewed with the director on nursing. The process utilized by the RN was described to the DON. She confirmed the nurse did not follow the policy. The policy specified handwashing was to be for 15 seconds, utilizing vigorous handwashing technique. Additionally, Resident #3 had been diagnosed with [REDACTED]. Review of the[DIAGNOSES REDACTED] policy revealed staff were to maintain stringent handwashing. b) Resident #84 A medical record review, completed on 12/18/13 at 9:00 a.m., revealed Resident #84 was being treated for [REDACTED]. During a random observation on 12/18/13 at 11:40 a.m., a visitor, identified as Family Member #1, was observed in Resident #84's room. The visitor was sitting on the resident's bed, but was not wearing a protective garment. An interview with Family Member #1, on 12/18/13 at 11:45 a.m., revealed he provided incontinence care for his father. He said he utilized gloves, but never wore a protective gown. Upon inquiry, he related the facility had informed him handwashing was very important, but could not remember whether he was informed to wear other protective gear. On 12/18/13 at 1:00 p.m., the care plan initiated on 11/04/13 was reviewed related to[DIAGNOSES REDACTED]. It noted level 2 precautions (or contact precautions) were in effect until 48 hours after symptoms subsided or antibiotic therapy was completed. Review of the infection control policy found it included level 2 precautions were to be followed when there was a high risk for transmission, such as fecal incontinence unconstrained by usual methods. An interview with the assistant director of nursing (ADON), Employee #80, indicated no evidence was available to indicate the family had been educated on how to care for a resident with[DIAGNOSES REDACTED]. Upon inquiry, the ADON said she was aware the resident's son provided incontinence care. The facility's infection control policy directed family and visitors were to be educated, and the education was to be documented in the medical record. Employee #80 confirmed that no evidence was available to indicate the family had been educated. Employee #40 (RN), the infection control coordinator, also confirmed she had provided no education to the family. c) Resident #59 On 12/18/13 at 9:34 a.m., an observation of the flushing procedure for a central venous catheter for Resident #59 was observed. A registered nurse (RN) (Employee #103) performed this procedure. During this procedure, Employee #103 placed the flush syringes on the resident's bed and not on a clean field. Employee #103 wiped off the connectors with an alcohol sponge and did not allow the connectors to air dry before attaching the flush syringe. A review of the facility procedure titled 5.1 Central Venous Catheter (CVC) Flushing was conducted on 12/19/13 at 10:30 a.m. The section titled Procedure included (5) Assemble equipment and supplies on clean work surface (6 ) Don gloves (7) Vigorously cleanse needleless connector with alcohol. Allow to air dry. In an interview on 12/19/13 at 11:00 a.m., the director of nursing (DON) confirmed the facility procedure for flushing an implanted central venous port was to place the flushes on a clean field, vigorously cleanse needleless connectors with alcohol and allow to air dry. The DON stated all nurses had been inserviced on the proper procedure when flushing central venous catheters and Employee #103 did not follow the proper procedure.",2016-12-01
7961,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-12-19,514,D,1,0,KHS011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to maintain accurate and complete records for two (2) of six (6) sample residents. A resident received a treatment without an order; an as needed (prn) medication did not have parameters for frequency of administration; and a care plan provided inaccurate information, and did not address the status of a feeding tube. Resident identifiers: #3 and #76. Facility census: 127. Findings included: a) Resident #3 1) The medical record was reviewed on 12/18/13 at 9:30 a.m. The initial nursing assessment indicated Resident #3 did not make even slight changes in body position by self. A progress note revealed medications were administered via an enteral tube. The history and physical, dated 12/15/13, noted [DIAGNOSES REDACTED]. Review of the care plan noted staff were to encourage the resident to consume all fluids. A physician's orders [REDACTED]. No care plan was initiated related to the enteral tube. 2) Additionally, the care plan included staff were to remind Resident #3 to use the call light when attempting to ambulate or transfer. An interview with Employee #15, a nursing assistant (NA), on 12/18/13 at 10:30 a.m., and Employee #2, director of nursing (DON), on 12/18/13 at 10:45 a.m., revealed Resident #3 was immobile, required total care, and did not utilize the call bell. The DON confirmed the medical record did not correctly portray the resident's status. b) Resident #76 Resident #76's medical record was reviewed on 12/18/13 at 4:35 p.m. physician's orders [REDACTED]. During an interview with Employee #80 (assistant director of nursing), she confirmed there was no way to know how frequently the resident could receive [MEDICATION NAME] based on the order. Additionally, review of the Medication Administration Record [REDACTED]. The ADON agreed the MAR indicated [REDACTED]. She said the order needed clarified.",2016-12-01
8724,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-04-03,241,E,1,0,GJF111,"Based on observation and staff interview, the facility failed to ensure dignity for the residents by not removing dirty dishes and old food from breakfast from the dining room area prior to the lunch meal. This had the potential to affect more than a limited number of residents. Facility Census: 126. Findings include: a) Upon observation of the dining room located at the end of 300 Hall, on 04/01/13 at 12:05 p.m., it was observed that a rolling dining cart was sitting along the side wall, with the door open. On this cart were four (4) trays which contained old food from breakfast and dirty breakfast dishes. At that time, the dining room had twelve (12) residents seated and waiting for lunch. It was observed the food that had been prepared for lunch was already out in the serving area. Interview with a cook, Employee #73, was conducted at that time. He was asked why the breakfast trays were still sitting in an open cart in the dining area when lunch was ready to be served. He stated the trays should have been taken to the back already. Resident #19 was observed seated at a table with his spouse within arms length of this cart containing the old food and dirty dishes. The resident was not able to answer questions. It was only after the issue was brought to the attention of the cook, did he advise kitchen staff to take the trays to the kitchen. The Nursing Home Administrator (NHA), Employee #109, as well as the Director of Nursing (DON), Employee #6, were advised of the findings at 12:15 p.m. on 04/01/13.",2016-04-01
8725,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-04-03,309,D,1,0,GJF111,"Based on record review and staff interview, the facility failed to ensure the highest practicable well-being of the resident by failing to initiate neuro checks on a resident who sustained a fall. This was found for one (1) of four (4) residents sampled. Resident Identifier: #127. Facility Census: 126. Findings include: a) Resident #127 Review of the residents' Falls Investigation Reports was conducted at 8:38 a.m. on 04/02/13. No injuries were noted with the exception of a fall which occurred on 01/29/13. That fall was unwitnessed, and the falls report included, Abrasion to the center of forehead measuring 3 cm x 1 cm. Laceration with swelling to left side of forehead measuring 0.1 x 0.1, and that neuro checks were initiated. However, there was no evidence to show the resident was followed up with neuro checks or sent to the hospital for evaluation. An interview was conducted with the Director of Nursing (DON), Employee #6, at 9:30 a.m. on 04/02/13 regarding the resident's fall on 01/29/13. The DON was shown the falls report for that fall. She was advised there was no neuro check sheet found in the chart, and the resident was not sent out to the hospital. She looked through the resident's chart and was unable to locate a neurocheck sheet dated for 01/29/13. At 11:55 a.m. on 04/02/13 the DON confirmed that she could not locate evidence that neurochecks had been initiated on the resident after the fall on 01/29/13.",2016-04-01
8726,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-04-03,323,E,1,0,GJF111,"Based on observation and staff interview, the facility failed to ensure the safety of residents by not storing items that had a potential to cause harm to residents, in a secure area. This had the potential to affect more than a limited number of residents. Facility Census: 126. Finding include. a) During the initial tour of the facility, at 11:40 a.m. on 04/01/13, the shower room on 300 Hall was observed. The door to the shower room had no lock and potentially hazardous items were unsecured. The door could be easily opened by lightly pulling on a handle on the outside of the door. These items were observed in the shower room on a shelf: 1) a container of Clorox Bleach wipes, with the lid loosened, 2) an individual razor, as well as a pack of unopened razors, 3) a can of shaving cream, 4) deodorant, 5) body wash, and 6) a large jug of body wash, 3/4 of the way full, with no lid was sitting on the floor of a shower stall. Interview with a registered nurse, (RN), Assistant Director of Nursing (ADON), Employee #52 was conducted at 11:52 a.m Employee #52 was observed the 300 Hall shower room. She confirmed they were not supposed to be there. When Employee #52 returned to the hallway, she was asked if there were any residents on the hallway who wandered. Employee #52 pointed out three (3) residents who wandered on the hall. These were residents #100, #93, and #98. All three (3) of these residents' rooms were in close proximity to the shower room. Interview with Nursing Home Administrator (NHA), Employee #109, and RN, Director of Nursing (DON), Employee #6, was conducted at 12:15 p.m. on 04/01/13. They are advised at that time of the items found in the shower room, as well as the issue with the residents who wandered. Both Employee #109 and Employee #6 were in agreement that this was a safety hazard.",2016-04-01
9447,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-28,225,D,0,1,UJUP11,"Based on personnel file review and staff interview, the facility did not perform thorough investigations into the past histories of individuals they considered hiring. The facility did not query the WV nurse aide registry for findings of abuse / neglect against one (1) applicant, and they did not query the licensing board or conduct an out-of-state criminal background check for another applicant who identified on her employment application as having prior residence and employment in the State of Georgia as a licensed nurse. Employee identifiers: #64 and #176. Facility census: 124. Findings include: a) Employees #64 and #176 On 04/25/11 at approximately 9:00 a.m., the personnel files for five (5) sampled employees were reviewed. Employee #58 (payroll, accounts payable, benefits coordinator) assisted in this review. The personnel file review revealed the facility had not queried the State nurse aide abuse registry to determine whether Employee #64, a licensed practical nurse hired on 02/15/11, had been listed on the registry for findings of resident abuse / neglect. The personnel file review also revealed Employee #176, a registered nurse (RN), had listed prior employment and residency in the state of Georgia on her employment application. The facility had failed to complete a search with the RN licensing board in Georgia and failed to conduct a criminal history search in the State of Georgia for this employee. Employee #58 verified these actions needed to be completed and preceded to perform these searches.",2015-11-01
9448,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-28,250,D,0,1,UJUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide medically-related social services to one (1) of thirty-two (32) Stage II sample residents who was had capacity to understand and maker her own informed health care decisions but whom staff did not inquire as to whether she wanted to pursue a consult to address identified dental health needs, in accordance with her care plan. Resident identifier: #242. Facility census:124. Findings include: a) Resident #242 Medical record review revealed this [AGE] year old female was admitted to the facility on [DATE]. The physician had declared the resident to have capacity to understand and make informed medical decisions. Review of the resident's minimum data set (MDS 3.0) found in Section L the assessor documented the resident had obvious or likely cavity or broken natural teeth. Further review of the resident's care plan revealed a problem statement, created on 03/30/11, which said: (Name of resident) requires assistance with her ADL (activities of daily living) care tasks secondary to recent hospitalization , 03/11 to 3/21/11 at (name of hospital) secondary to bilateral PE and DVT's (deep vein thrombosis) along with multiple co-morbidities. The goal for this problem statement was: (Name of resident) will complete her self-care with limited staff assistance after set up, by the next review period. Interventions to assist the resident in achieving this goals included: (name of resident) has her own natural teeth on the top and bottom. Ensure that her oral hygiene is being completed q day and as needed. Refer to SS (social services) if she is in need of a dental consult. The interim director of nursing (DON - Employee #109), when interviewed at 2:45 p.m. on 04/25/11, stated she would talk to the physician and see if the resident needed a dental consult. The DON was unable to provide any evidence the dental issues had been addressed and/or the care plan updated to reflect the resident's wishes. The social service director (Employee #83), when interviewed on 04/26/11 at approximately 5:10 p.m., stated she had not spoken to the resident about her dental issues and did not know if she needed or wanted a dental consult. Employee #83 also stated she did not know this approach was on the care plan.",2015-11-01
9449,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-28,272,D,0,1,UJUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and care plan review, the facility failed to conduct, initially and periodically, a comprehensive and accurate assessment of each resident, as evidenced by the facility's failure to complete weekly skin assessment for one (1) resident with a wound (#4). One (1) of thirty-two (32) Stage II sample residents were affected. Resident identifier: #4. Facility census: 124. Findings include: a) Resident #4 Review of Resident #4's medical record revealed the treatment administration record (TAR) contained an order for [REDACTED]. On 04/27/11 at 2:10 p.m., an interview with the corporate nurse consultant (Employee #54) revealed that, if the skin assessments were completed, the TAR would be initialed and only significant findings would be documented in the nursing notes. Review of the resident's medical record found no nursing notes for 04/01/11 or 04/15/11.",2015-11-01
9450,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-28,279,D,0,1,UJUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and care plan review, the facility failed to use the results of each resident comprehensive assessment to develop a comprehensive plan of care to address the specific needs of two (2) of thirty-two (32) Stage II sample residents. The facility failed to develop a care plan to address a resident's contractures of her lower extremities (#3) and failed provide appropriate interventions to prevent dehydration for a resident (#48). Resident identifiers: #3 and #61, #48. Facility census: 124. Findings include: a) Resident #3 Observation, on 04/26/11 at 1:55 p.m., found Resident #3 lying in bed with no adaptive equipment in use and improperly positioned. Further observation found the resident's lower extremities were contracted. Review of the resident's interdisciplinary therapy screen revealed, on 04/27/10, the resident was identified as having contractures of (B) LE (bilateral lower extremities) hips. Further review of Resident #3's medical record found no care plan to address the resident's contractures. On 04/26/11 at 4:30 p.m., an interview with the interim director of nursing (DON - Employee #109) confirmed no care plan could be found regarding the resident's contractures, and Employee #109 further stated the resident should have a care plan addressing the contractures. -- b) Resident #48 Medical record review disclosed this resident was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of a laboratory report dated 12/22/10 revealed the resident's BUN (Blood Urea Nitrogen) was elevated at 34 (normal range is 6 - 20). An elevated BUN is indicative for impaired kidney function. Further review of the lab reports revealed, on 01/25/11, the resident's BUN was even more elevated at 44. On 01/25/11, the physician ordered blood work (BMP) in one (1) week due to dehydration. Meal observations conducted during the course of the survey found the resident refused meals and fluids and required much encouragement and assistance from staff to promote oral intake. Interview with a nursing assistant (Employee #101), on 04/26/11, and on 04/27/11, found the resident often refused food / fluids and other care. Review of the resident's comprehensive care plan, dated 01/28/11, found the following intervention on page 6 of 18: Observe resident for signs / symptoms of dehydration (increase temp, decrease output, mental status changes, dry mucous membranes, orthostatic [MEDICAL CONDITIONS]. Further medical record review found no evidence to reflect the staff had been monitoring the resident for orthostatic [MEDICAL CONDITIONS] or evidence of decreased urinary output. The problem of dehydration had been identified on the comprehensive care plan, but interventions focused on monitoring for the development of dehydration and not on prevention of dehydration through promotion of adequate fluid intake.",2015-11-01
9451,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-28,280,D,0,1,UJUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and care plan review, the facility failed to revise the care plans of three (3) of thirty-two (32) Stage II sample residents when changes occurred or were needed in their treatment. The facility failed to revise one (1) resident's care plan with respect to altered skin integrity until after an area of incontinence-associated dermitis developed into a Stage 3 pressure ulcer on her coccyx (#92); failed to revise one (1) resident's care plan to reflect changes in treatment that were ordered to promote wound healing for existing skin breakdown and failed to update the care plan when a new deep tissue injury developed on her coccyx (#150); and failed to revise a resident's care plan to address her problematic dental conditions (#242). Resident identifiers: #92, #150, and #242. Facility census: 124. Findings include: a) Resident #92 1. Review of Resident #92's skin integrity report, with an initial date of 01/06/11 that resident was noted to have [MEDICAL CONDITION] to her buttocks / coccyx area. No further description of the area's characteristics was provided for this date, such as a description of the area's appearance or any measurements of the area's dimensions. An entry on this skin integrity report, dated 01/09/11, indicated no pressure ulcer was present, the skin's appearance was described as I (intact/pink), the area measured as 5.25 cm x 2 cm with no depth, and no update was made to the resident's care plan. The next entry on the skin integrity report, dated 01/16/11, indicated no pressure ulcer was present, the appearance of the area of [MEDICAL CONDITION] was coded I, scattered written in lieu of any measurements of the area's dimensions, with no change in the area and no update made to the resident's care plan. Entries dated 01/23/11 and 01/30/10 related similar details. The next entry on the skin integrity report, dated 02/07/11, indicated no pressure ulcer was present, the appearance of the area was coded I/peeling with scattered in lieu of any measurements of the area's dimensions. The block for indicating whether any updates were made to the resident's care plan was left blank. The next entry dated 02/14/11 was the same. (Note the assessor was using the terms I (for intact/pink) and peeling simultaneously to describe the area's appearance.) An entry dated 02/21/11 indicated no pressure ulcer was present, the appearance of the area was coded as I/flaking with scattered written in lieu of any measurements of the area's dimensions. There was no change in the area, and the block for indicating whether any updates were made to the resident's care plan was left blank. The next entry on the skin integrity report, dated 02/28/11, indicated no pressure ulcer was present, the appearance of the area was coded as I/peeling with scattered in lieu of any measurements of the area's dimensions. The block for indicating whether any updates were made to the resident's care plan was left blank. The next entry on the skin integrity report, dated 03/06/11, indicated no pressure ulcer was present, the appearance of the area was coded as I/peeling, with scattered written in lieu of any measurements of the area's dimensions, no change in the area, and no update made to the resident's care plan. The next entry on the skin integrity report, dated 03/14/11, indicated no pressure ulcer was present, the appearance of the area was coded as I/peeling with scattered in lieu of any measurements of the area's dimensions. The block for indicating whether any updates were made to the resident's care plan was left blank. The next entry on the skin integrity report, dated 03/20/11, indicated no pressure ulcer was present, the appearance of the area was coded as SB (blister/serous), the area now measured 8 cm x 5 cm x 0.2 cm with SS (serosanguineous) drainage present. The assessor coded the wound edges as R (rolled), and no changes were made to the resident's care plan. The next entry on this form was a handwritten note stating, See new sheet 3/23/11. Documentation on the new skin integrity sheet identified the initial status of the area on the resident's coccyx / buttocks noted the presence of an IHA (in-house acquired) Stage 3 pressure ulcer identified on 03/23/11. The appearance of the area was coded as G / S10% / E (granulation / slough 10% / [MEDICATION NAME]), the area now measured 8.0 cm x 7.5 cm x 0.3 cm with min SS (minimal serosanguineous) drainage and healthy edges present, and no changes were made to the resident's care plan. - 2. Review of Resident #92's care plan found the following problem statement, which was created on 10/22/08 and revised on 03/23/11 (quoted as typed): Resident is at risk for skin breakdown due to decreased mobility and incontinence related to a history of advanced dementia and OA ([MEDICAL CONDITION]) and OP ([MEDICAL CONDITION]). Eval: Continue with focus, goal and interventions. Stage II noted to right heel and stage III noted to left heel per skin intergrity report on 9/21/10. 12/15/10 Eval: Continue with focus, goal and interventions. Stage II noted to left heel per wound report. 1/20/11 Stage III to left heel resolved. (Resident #92) has IAD (incontinence-associated [MEDICAL CONDITION]) notes to buttocks, noted to be improving. 2-10-11- IAD on buttocks. 3/19/11: (Resident #92) continues to have IAD to buttocks. She remains at severe risk for further breakdown related to poor p.o. (oral) intake, hx (history) of pressure ulcers, incontinence, general debility. 3/23/11: IAD on coccyx / buttocks now noted to be St III (Stage 3 pressure ulcer). Remains at severe risk for furhetr breakdown d/t (due to) hx PUs (pressure ulcers), incontinence, and limited mobility. The goal associated with this problem statement was: (Resident #92) will not show signs of skin breakdown through next review. The interventions established to achieve this goal were (quoted as typed): Provide prompt peri-care after each episode of incontinence. Apply INZO cream to affected areas with each cleansing. Monitor skin for signs / symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily. Provide supplements as ordered. Evaluate for any localized skin problems, i.e. dryness, redness, pustules, inflammation with AM (morning) care. Observe skin condition with ADL care daily and report. LALM (low air loss mattress) with side bolsters. All of the above interventions had creation dates of 10/22/08, with the exception of the LALM, which was added on 03/23/11 - after the Stage 3 pressure ulcer was identified. No new interventions were implemented to address pressure ulcer prevention once the IAD was identified on the resident's buttocks / coccyx until after the area developed into a Stage 3 pressure ulcer. - 3. Review of Resident #92's physician's orders [REDACTED]. On 02/21/11, the physician discontinued the skin paste and ordered INZO cream to the buttocks every shift for excoriation. On 03/23/11, the physician discontinued the INZO cream to the buttocks, ordered the LALM, and ordered the following wound treatment (quoted as written): Cleanse coccyx / Buttocks /c (with) wound cleanser. Pat dry. Apply Sureprep around wound. Apply Hydrogel gauze to wound & cover /c dry dressing. Change daily & PRN (as needed). On 04/22/11, the physician ordered (quoted as written), To be up in geri-chair with two pillows vertical behind her back to float her spine. And one pillow under her calves to float her heels. Review of the resident's nursing progress notes revealed no additional interventions regarding the prevention of the pressure ulcer to the resident's coccyx. Review of the resident's therapy progress notes revealed no interventions to address the prevention of pressure ulcer development on the resident's coccyx / buttocks were initiated until 03/24/11, after the Stage 3 pressure ulcer was identified. - 4. On 04/28/11 at 10:20 a.m., an interview with a corporate nurse consultant (Employee #54) revealed all interventions, to address pressure ulcer prevention and/or treatment, should have been listed on the care plan or in the progress notes. On 04/28/11 at 10:30 a.m., an interview with the RN (Employee #84) revealed there were no other interventions in place, other than application of the INZO cream to the coccyx. An interview with the therapy program manager (Employee #6) confirmed that therapy interventions to address the treatment of [REDACTED]. -- b) Resident #150 1. Review of Resident #150's care plan, on 04/25/11 at approximately 9:45 a.m., revealed the following problem statement (quoted as typed): (Resident #150) has actual skin breakdown AEB (as evidenced by) the stage I PU (pressure ulcer) located on her bilateral heels; She is at risk for further breakdown secondary to her impaired mobility and non ambulatory status, incontinence and contractures of her upper and lower extremities. The goal for this problem statement was: Existing affected areas will remain free from s/s (signs / symptoms) of deterioration and her unaffected skin will remain intact, free from [DIAGNOSES REDACTED], breakdown excoriation through the next review period. The interventions intended to assist the resident in achieving that goal were (quoted as typed): Apply barrier cream with each dressing. Evaluate for any localized skin problems i.e. dryness, redness, pustules, inflammation. Notify physician of lack of progress in healing or deterioration. Observe (Resident #150) for and assist her with her toileting needs as she is incontinent of bowel and bladder. Observe (Resident #150's) skin for signs / symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation and skin that does not blanche easily. Observe skin condition with ADL care daily and report abnormalities. Padded cover for Geri chair to be on chair when resident is up in chair. - 2. Further medical record review revealed a physician's orders [REDACTED]. Remove Profo boots to check skin integrity - Q (every) shift. The physician's orders [REDACTED]. The resident also had ordered to receive health shakes three (3) times per day beginning on 09/10/10 and [MEDICATION NAME] 4 mg every day due to weight loss beginning on 03/04/11. None of these physician-ordered interventions to promote wound healing were included in the resident's care plan. - 3. In an interview with a registered nurse (RN) unit manager (Employee #52) on 04/28/11 at 11:30 a.m., Employee #52 stated the Stage II on the resident's coccyx / left buttock started out as a deep tissue injury; on 03/14/11, it developed into a Stage II pressure ulcer. Employee #52 stated the staff takes the resident to the dining room last and takes her back to her room immediately upon finishing her meal, to prevent her from lying in the geri-chair for extended periods of time. The care plan did not list this as an intervention to prevent further breakdown to the coccyx. Employee #52 reported Resident #150 normally consumes 100% of the health shakes she receives, and she noted that the [MEDICATION NAME] served to increase the resident's appetite. The care plan did not list these nutritional interventions used to promote wound healing. - 4. In addition, the facility had not updated Resident #150's care plan to reflect the deep tissue injury to the left coccyx. As of 03/14/11, skin integrity reports showed the deep tissue injury changed to a Stage 2 pressure ulcer, and the care plan was last revised five (5) days later, on 03/19/11. -- c) Resident #242 Medical record review revealed this [AGE] year old female was admitted to the facility on [DATE]. The physician had declared the resident to have capacity to understand and make informed medical decisions. Review of the resident's minimum data set (MDS 3.0) found in Section L the assessor documented the resident had obvious or likely cavity or broken natural teeth. Further review of the resident's care plan revealed a problem statement, created on 03/30/11, which said: (Name of resident) requires assistance with her ADL (activities of daily living) care tasks secondary to recent hospitalization , 03/11 to 3/21/11 at (name of hospital) secondary to bilateral PE and [MEDICAL CONDITION]'s ([MEDICAL CONDITION] along with multiple co-morbidities. The goal for this problem statement was: (Name of resident) will complete her self-care with limited staff assistance after set up, by the next review period. Interventions to assist the resident in achieving this goals included: (name of resident) has her own natural teeth on the top and bottom. Ensure that her oral hygiene is being completed q day and as needed. Refer to SS (social services) if she is in need of a dental consult. The interim director of nursing (DON - Employee #109), when interviewed at 2:45 p.m. on 04/25/11, stated she would talk to the physician and see if the resident needed a dental consult. The DON was unable to provide any evidence the dental issues had been addressed and/or the care plan updated to reflect the resident's wishes. The social service director (Employee #83), when interviewed on 04/26/11 at approximately 5:10 p.m., stated she had not spoken to the resident about her dental issues and did not know if she needed or wanted a dental consult. Employee #83 also stated she did not know this approach was on the care plan.",2015-11-01
9452,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-28,309,G,0,1,UJUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each resident received care and services to assist them in attaining and/or maintaining their highest practicable level of well-being, affecting two (2) of thirty-two (32) Stage II sample residents and resulting in actual harm to one (1) of these residents (#61). Resident #61, who was readmitted to the facility on [DATE], was receiving multiple antihypertensive (blood-pressure reducing) medications for hypertension (high blood pressure), for which staff was to assess her blood pressure prior to administration and hold these medications if her systolic blood pressure (SBP) was greater than 110 mmHg. On 12/17/10, 12/18/10, 12/19/10, 12/20/10, and on the morning of 12/21/10, Resident #61 received scheduled doses of antihypertensives without evidence that staff had assessed her SBP prior to each dose. At 10:00 a.m. on 12/21/10, Resident #61 was transferred to the hospital for low blood pressure. Resident #48's personal preferences for advance directives, as expressed on the resident's Physician order [REDACTED]. The resident's monthly recapitulation of physician's orders [REDACTED]. not honoring the resident's advance directives for end-of-life care. Resident identifiers: #61 and #48. Facility census: 124. Findings include: a) Resident #61 Medical record review revealed this [AGE] year old female's active [DIAGNOSES REDACTED]. The resident was receiving [MEDICAL TREATMENT] outside the facility on Monday, Wednesday, and Friday. Further review revealed the resident's initial admission to the facility was on 11/23/10. She had several admissions and discharges to the facility before her discharge to home on 02/09/11. The resident was re-admitted to the facility on [DATE]. Review of the December 2010 Medication Administration Record [REDACTED] - [MEDICATION NAME] 2 mg by mouth three (3) times a day (TID) at 8:00 a.m., 2:00 p.m., and 10:00 p.m. - [MEDICATION NAME] 50 mg by mouth TID at 8:00 a.m., 2:00 p.m., and 10:00 p.m. Hold if SBP is less than 110. - [MEDICATION NAME] 5 mg by mouth two (2) times at day (BID) at 9:00 a.m. and 9:00 p.m. Hold if SBP is less than 110. - [MEDICATION NAME] 0.2 mg by mouth TID at 6:00 a.m., 2:00 p.m., and 10:00 p.m. Hold if SBP is less than 110. According to the physician's orders [REDACTED]. This would require nursing staff to obtain the resident's SBP daily at the following times: 6:00 a.m., 8:00 a.m., 9:00 a.m., 2:00 p.m., and 10:00 p.m., to assure the SBP was not less than 110 mmHg before administering the medications prescribed to treat the resident's hypertension. On 12/17/10, the resident was readmitted to the facility at 8:28 p.m. The facility obtained the resident's blood pressure at 8:28 p.m., according to documentation on the weights and vitals summary. Review of the MAR indicated [REDACTED] On 12/18/10, the facility obtained the resident's blood pressure at 9:37 a.m., according to documentation in the facility's weights and vitals summary. According to documentation on the MAR, nursing staff administered [MEDICATION NAME] 50 mg at 8:00 a.m., 2:00 p.m., and 10:00 p.m.; [MEDICATION NAME] 25 mg at 8:00 a.m., 2:00 p.m., and 10:00 p.m.; [MEDICATION NAME] 0.2 mg at 6:00 a.m., 2:00 p.m., and 10:00 p.m.; and [MEDICATION NAME] 5 mg at 9:00 a.m. On 12/19/10, the resident's blood pressure was obtained at 7:41 p.m., according to the documentation in the facility's weights and vitals summary. Documentation on the MAR indicated [REDACTED] On 12/20/10, the resident's blood pressure was obtained at 4:53 p.m. and 7:12 p.m., according to the documentation on the facility's weights and vitals summary; however, nursing notes written on 12/20/10 stated the resident was out of the facility at [MEDICAL TREATMENT] and did not return to the facility until 6:00 p.m. on 12/20/10. Review of the MAR indicated [REDACTED] On 12/21/10, a nursing note documented the resident's blood pressure was 87/37 when obtained at 10:00 a.m. The resident was sent to the hospital. Further review of the medical record revealed a transfer form to the hospital which documented the reason for the transfer as: BP (blood pressure) 88/37 (symbol for arrow) 80/40 P (pulse) 67. The 12/21/10, a nursing note also documented, . AM (morning) meds. (medications) not given d/t (due to) low BP. Review of the MAR indicated [REDACTED]. There was no evidence the resident's SBP pressure was verified before administering the 6:00 a.m. dose of [MEDICATION NAME]. In an interview with the facility's acting director of nursing on the afternoon of 04/26/11, she verified the resident's blood pressures would be documented in the nursing notes or on the weights and vital summary. She was unable to produce documentation to verify the resident's SBP was consistently obtained as ordered by the physician before administering the above antihypertensive medications at the documented dates and times. She was unable to explain how the resident's blood pressure was obtained at 4:53 p.m. on 12/20/10 when the resident was not at the facility. Multiple antihypertensive medications were administered daily from 12/17/10 through 12/21/10, at numerous times throughout the day, without first verifying the resident's SBP was not less than 110 mmHg, as directed by the resident's physician. The resident was transferred to the hospital for low blood pressure on 12/21/10. -- b) Resident #48 Review of Resident #48's monthly recapitulation of physician's orders [REDACTED].>Review of the resident's POST form, dated 11/19/10, found in Section B the resident had chosen limited additional interventions. Review of Section E of the POST form also found the basis for this order was the resident's personal preferences, which had been discussed with the health care surrogate (HCS). In an interview on 04/28/11 at 9:30 a.m., the registered nurse (RN) unit manager (Employee #52) disclosed the resident's HCS had rejected an offer of hospice services, because he did not want comfort measures only. Employee #52 also confirmed, during this interview, that the monthly recap orders did not agree with the information found on the resident's POST form respect to advance directives.",2015-11-01
9453,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-28,314,G,0,1,UJUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident did not develop pressure ulcers unless the resident's clinical condition demonstrated they were unavoidable. On 01/06/11, a nurse assessed Resident #92 (who had no history of a pressure ulcer to her coccyx since at least 10/01/09) as having an area on her coccyx measuring 5.25 cm x 2 cm x 0 cm and identified as incontinence-associated [MEDICAL CONDITION] or IAD. According to a skin integrity report with entries made weekly from 01/09/11 until 03/20/11, the alteration in skin integrity on the resident's coccyx / buttocks continued to be identified as IAD. On 03/23/11, the area was then identified as a Stage 3 pressure ulcer measuring 8.0 cm x 7.5 cm x 0.3 cm with granulation, slough, and [MEDICATION NAME] tissue present. No interventions had been implemented to prevent worsening of the area of altered skin integrity, other than the application of INZO (invisible zinc oxide) cream, until after it was identified as a Stage 3 pressure sore. This resulted in actual harm to one (1) of thirty-two (32) Stage II sample residents. Resident identifier: #92. Facility census: 124. Findings include: a) Resident #92 1. Review of Resident #92's most recent comprehensive assessment, an annual minimum data set version 3.0 (MDS 3.0) with an assessment reference date (ARD) of 03/08/11, revealed this [AGE] year old female was admitted to the facility on [DATE]. In Section G, the assessor noted Resident #92 was totally dependent on staff for all activities of daily living including bed mobility, transferring, and toilet use, with impairments on both sides with functional limitations in range of motion in her upper and lower extremities. In Section I, the assessor noted her active diagnoses, including [MEDICAL CONDITION], dementia other than Alzheimer's, [MEDICAL CONDITIONS], cancer, wound infection (other than foot), and cardiac [MEDICAL CONDITION]. In Section M, the assessor indicated Resident #92 was at risk for developing pressure ulcers (based on the use of a formal assessment instrument / tool and clinical assessment), she did not currently have any unhealed pressure ulcers, and no pressure ulcers were present on the prior MDS. Also in Section M, the assessor noted that none of the following conditions was present: infection of the foot, [MEDICAL CONDITION](s), other open [MEDICAL CONDITION] on the foot, open lesion(s) other than ulcers, rashes, cuts, surgical wound(s), and burn(s). According to documentation in Section M1200 (skin and ulcer treatments), Resident #92 was receiving a pressure reducing device for her chair and bed, a turning / repositioning program, the application of non-surgical dressings other than to feet, and the application of ointments / medications other than to feet. -- 3. Review of Resident #92's previous assessment, an abbreviated quarterly MDS 3.0 with an ARD of 12/12/10, revealed the following information in Section M: She was at risk for developing a pressure ulcer (based the presence of a Stage 1 or greater ulcer, scar over bony prominence or a non-removable dressing / device, the use of a formal assessment instrument / tool, and clinical assessment), and she currently had an unhealed pressure ulcer at Stage 3 measuring 0.6 cm x 0.5 cm x 0.1 cm for which she was receiving a pressure reducing device for her chair and bed, ulcer care, and the application of ointments / medications other than to feet. -- 4. On 04/27/11 at 12:30 p.m., an interview with a registered nurse (RN - Employee #84) revealed Resident #92 had a pressure ulcer that was acquired in-house. -- 5. Review of Resident #92's skin integrity report, with an initial date of 01/06/11 that resident was noted to have [MEDICAL CONDITION] to her buttocks / coccyx area. No further description of the area's characteristics was provided for this date, such as a description of the area's appearance or any measurements of the area's dimensions. An entry on this skin integrity report, dated 01/09/11, indicated no pressure ulcer was present, the skin's appearance was described as I (intact/pink), the area measured as 5.25 cm x 2 cm with no depth, and no update was made to the resident's care plan. The next entry on the skin integrity report, dated 01/16/11, indicated no pressure ulcer was present, the appearance of the area of [MEDICAL CONDITION] was coded I, scattered written in lieu of any measurements of the area's dimensions, with no change in the area and no update made to the resident's care plan. Entries dated 01/23/11 and 01/30/10 related similar details. The next entry on the skin integrity report, dated 02/07/11, indicated no pressure ulcer was present, the appearance of the area was coded I/peeling with scattered in lieu of any measurements of the area's dimensions. The block for indicating whether any updates were made to the resident's care plan was left blank. The next entry dated 02/14/11 was the same. (Note the assessor was using the terms I (for intact/pink) and peeling simultaneously to describe the area's appearance.) An entry dated 02/21/11 indicated no pressure ulcer was present, the appearance of the area was coded as I/flaking with scattered written in lieu of any measurements of the area's dimensions. There was no change in the area, and the block for indicating whether any updates were made to the resident's care plan was left blank. The next entry on the skin integrity report, dated 02/28/11, indicated no pressure ulcer was present, the appearance of the area was coded as I/peeling with scattered in lieu of any measurements of the area's dimensions. The block for indicating whether any updates were made to the resident's care plan was left blank. The next entry on the skin integrity report, dated 03/06/11, indicated no pressure ulcer was present, the appearance of the area was coded as I/peeling, with scattered written in lieu of any measurements of the area's dimensions, no change in the area, and no update made to the resident's care plan. The next entry on the skin integrity report, dated 03/14/11, indicated no pressure ulcer was present, the appearance of the area was coded as I/peeling with scattered in lieu of any measurements of the area's dimensions. The block for indicating whether any updates were made to the resident's care plan was left blank. The next entry on the skin integrity report, dated 03/20/11, indicated no pressure ulcer was present, the appearance of the area was coded as SB (blister/serous), the area now measured 8 cm x 5 cm x 0.2 cm with SS (serosanguineous) drainage present. The assessor coded the wound edges as R (rolled), and no changes were made to the resident's care plan. The next entry on this form was a handwritten note stating, See new sheet 3/23/11. Documentation on the new skin integrity sheet identified the initial status of the area on the resident's coccyx / buttocks noted the presence of an IHA (in-house acquired) Stage 3 pressure ulcer identified on 03/23/11. The appearance of the area was coded as G / S10% / E (granulation / slough 10% / [MEDICATION NAME]), the area now measured 8.0 cm x 7.5 cm x 0.3 cm with min SS (minimal serosanguineous) drainage and healthy edges present, and no changes were made to the resident's care plan. -- 6. Review of the resident's past MDS assessment revealed Resident #92 was admitted to the facility on [DATE] with no pressure ulcers present on admission. Review of her minimum data set version 2.0 (MDS 2.0) assessments from her annual comprehensive assessment with an assessment reference date (ARD) of 10/01/09 through an abbreviated quarterly assessment with an ARD of 07/13/10 revealed she had no pressure ulcers during any of the assessment reference periods, to include no pressure ulcers present when she returned to the facility from hospital stays on 04/15/10 and 05/26/10. On her abbreviated quarterly MDS 2.0 with an ARD of 09/22/10, the assessor noted the presence of two (2) pressure ulcers - one (1) Stage 2 and one (1) Stage 3, which were acquired in-house. One (1) of these pressure ulcers was healed prior to the MDS of 12/12/10, and the other was healed prior to the MDS 3.0 of 03/08/11, although the MDS 3.0 of 03/08/11 did not acknowledge the presence of a pressure ulcer having been encoded on the preceding MDS. According to her MDS assessments from 10/01/09 through the present, her mobility was impaired, she was incontinent of bowel and bladder, and she was totally dependent on staff for ADL performance. These risk factors for pressure sore development were not new for this resident. -- 7. Review of Resident #92's care plan found the following problem statement, which was created on 10/22/08 and revised on 03/23/11 (quoted as typed): Resident is at risk for skin breakdown due to decreased mobility and incontinence related to a history of advanced dementia and OA ([MEDICAL CONDITION]) and OP ([MEDICAL CONDITION]). Eval: Continue with focus, goal and interventions. Stage II noted to right heel and stage III noted to left heel per skin intergrity report on 9/21/10. 12/15/10 Eval: Continue with focus, goal and interventions. Stage II noted to left heel per wound report. 1/20/11 Stage III to left heel resolved. (Resident #92) has IAD (incontinence-associated [MEDICAL CONDITION]) notes to buttocks, noted to be improving. 2-10-11- IAD on buttocks. 3/19/11: (Resident #92) continues to have IAD to buttocks. She remains at severe risk for further breakdown related to poor p.o. (oral) intake, hx (history) of pressure ulcers, incontinence, general debility. 3/23/11: IAD on coccyx / buttocks now noted to be St III (Stage 3 pressure ulcer). Remains at severe risk for furhetr breakdown d/t (due to) hx PUs (pressure ulcers), incontinence, and limited mobility. The goal associated with this problem statement was: (Resident #92) will not show signs of skin breakdown through next review. The interventions established to achieve this goal were (quoted as typed): Provide prompt peri-care after each episode of incontinence. Apply INZO cream to affected areas with each cleansing. Monitor skin for signs / symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily. Provide supplements as ordered. Evaluate for any localized skin problems, i.e. dryness, redness, pustules, inflammation with AM (morning) care. Observe skin condition with ADL care daily and report. LALM (low air loss mattress) with side bolsters. All of the above interventions had creation dates of 10/22/08, with the exception of the LALM, which was added on 03/23/11 - after the Stage 3 pressure ulcer was identified. No new interventions were implemented to address pressure ulcer prevention once the IAD was identified on the resident's buttocks / coccyx until after the area developed into a Stage 3 pressure ulcer. - 8. Review of Resident #92's physician's orders [REDACTED]. On 02/21/11, the physician discontinued the skin paste and ordered INZO cream to the buttocks every shift for excoriation. On 03/23/11, the physician discontinued the INZO cream to the buttocks, ordered the LALM, and ordered the following wound treatment (quoted as written): Cleanse coccyx / Buttocks /c (with) wound cleanser. Pat dry. Apply Sureprep around wound. Apply Hydrogel gauze to wound & cover /c dry dressing. Change daily & PRN (as needed). On 04/22/11, the physician ordered (quoted as written), To be up in geri-chair with two pillows vertical behind her back to float her spine. And one pillow under her calves to float her heels. Review of the resident's nursing progress notes revealed no additional interventions regarding the prevention of the pressure ulcer to the resident's coccyx. Review of the resident's therapy progress notes revealed no interventions to address the prevention of pressure ulcer development on the resident's coccyx / buttocks were initiated until 03/24/11, after the Stage 3 pressure ulcer was identified. -- 9. On 04/28/11 at 10:20 a.m., an interview with a corporate nurse consultant (Employee #54) revealed all interventions, to address pressure ulcer prevention and/or treatment, should have been listed on the care plan or in the progress notes. On 04/28/11 at 10:30 a.m., an interview with the RN (Employee #84) revealed there were no other interventions in place, other than application of the INZO cream to the coccyx. An interview with the therapy program manager (Employee #6) confirmed that therapy interventions to address the treatment of [REDACTED].",2015-11-01
9454,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-28,323,D,0,1,UJUP11,"Part I -- Based on observation, medical record review, and staff interview, the facility failed to remove side rails from a resident's bed after the physician wrote an order to discontinue the side rails. This was true for one (1) of thirty-two (32) Stage II sample residents. Resident identifier: #82. Facility census: 124. Findings include: a) Resident #82 Observation, on 04/20/11 at approximately 2:35 p.m., found Resident #82 lying in bed with bilateral side rails in the up position. A gap measuring approximately 3 inches in width was observed between the mattress's edge and side rails. The acting director of nursing (DON - Employee #109) and the administrator (Employee #81) were summoned to view the resident's side rails. At approximately 3:30 p.m. on 04/20/11, the DON stated the resident had been re-evaluated and the side rails had been discontinued. Review of Resident #82's medical record found a nursing note, dated 02/09/11, stating: Received order to discontinue side rails due to they pose more of a risk than benefit and resident unable to use them on command. Review of the treatment administration record (TAR) revealed the order for the side rails was discontinued on 02/09/11. On 04/26/11 at approximately 5:30 p.m., the DON, when interviewed regarding the above findings, was unable to provide any additional information as to why the side rails were observed in use on the resident's bed on 04/20/11 when the side rails were discontinued by the physician on 02/09/11. --- Part II -- Based on observation and staff interview, the facility failed to ensure the resident's call light system was in good working condition. Observation revealed electrical wires were exposed in the call light in Room 110. Facility census: 124. Findings include: a) Room 110 On 04/20/11 at 2:20 p.m., observation of the interior of Room 110 on North hall, found the call light housing unit was observed pulled out of the wall with electrical wires exposed. On 04/20/11 at 2:25 p.m., a second surveyor verified this same observation - that the call light housing unit was pulled out of the wall with electrical wires exposed. On 04/20/11 at 3:15 p.m., an interview with the maintenance helper (Employee #106) revealed the exposed electrical wires had the potential to shock someone. He further stated that the shock could be damaging or fatal to an elderly individual whose health was otherwise compromised. Employee #106 also stated these new call light housing units had just been installed last week. During the above observations, no residents were noted to have approached the exposed wires, and it could not be ascertained how long the wires had been exposed. Immediately following this interview, the maintenance helper (Employee #106) and the maintenance director (Employee #16) repaired the call light.",2015-11-01
9455,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-28,329,G,0,1,UJUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide adequate monitoring for two (2) of thirty-two (32) Stage II sample residents whose medication regimens included duplicate therapy and/or medication contraindicated for use with the elderly, resulting in actual harm to one (1) of these residents (#61). Resident #61, who was readmitted to the facility on [DATE], was receiving multiple antihypertensive (blood-pressure reducing) medications for hypertension (high blood pressure), for which staff was to assess her blood pressure prior to administration and hold these medications if her systolic blood pressure (SBP) was greater than 110 mmHg. On 12/17/10, 12/18/10, 12/19/10, 12/20/10, and on the morning of 12/21/10, Resident #61 received scheduled doses of antihypertensives without evidence that staff had assessed her SBP prior to each dose. At 10:00 a.m. on 12/21/10, Resident #61 was transferred to the hospital for low blood pressure. Resident #94, a [AGE] year old female resident, was receiving [MEDICATION NAME] three (3) times a day for neck pain, and the use of [MEDICATION NAME] (a drug not recommended for long term use in the elderly due to the potential harmful side effects) was not being monitored as required for Resident #94. Resident identifiers: #61 and 94. Facility census: 124. Findings include: a) Resident #61 Medical record review revealed this [AGE] year old female's active [DIAGNOSES REDACTED]. The resident was receiving [MEDICAL TREATMENT] outside the facility on Monday, Wednesday, and Friday. Further review revealed the resident's initial admission to the facility was on 11/23/10. She had several admissions and discharges to the facility before her discharge to home on 02/09/11. The resident was re-admitted to the facility on [DATE]. Review of the December 2010 Medication Administration Record [REDACTED] - [MEDICATION NAME] 2 mg by mouth three (3) times a day (TID) at 8:00 a.m., 2:00 p.m., and 10:00 p.m. - [MEDICATION NAME] 50 mg by mouth TID at 8:00 a.m., 2:00 p.m., and 10:00 p.m. Hold if SBP is less than 110. - [MEDICATION NAME] 5 mg by mouth two (2) times at day (BID) at 9:00 a.m. and 9:00 p.m. Hold if SBP is less than 110. - [MEDICATION NAME] 0.2 mg by mouth TID at 6:00 a.m., 2:00 p.m., and 10:00 p.m. Hold if SBP is less than 110. According to the physician's orders [REDACTED]. This would require nursing staff to obtain the resident's SBP daily at the following times: 6:00 a.m., 8:00 a.m., 9:00 a.m., 2:00 p.m., and 10:00 p.m., to assure the SBP was not less than 110 mmHg before administering the medications prescribed to treat the resident's hypertension. On 12/17/10, the resident was readmitted to the facility at 8:28 p.m. The facility obtained the resident's blood pressure at 8:28 p.m., according to documentation on the weights and vitals summary. Review of the MAR indicated [REDACTED] On 12/18/10, the facility obtained the resident's blood pressure at 9:37 a.m., according to documentation in the facility's weights and vitals summary. According to documentation on the MAR, nursing staff administered [MEDICATION NAME] 50 mg at 8:00 a.m., 2:00 p.m., and 10:00 p.m.; [MEDICATION NAME] 25 mg at 8:00 a.m., 2:00 p.m., and 10:00 p.m.; [MEDICATION NAME] 0.2 mg at 6:00 a.m., 2:00 p.m., and 10:00 p.m.; and [MEDICATION NAME] 5 mg at 9:00 a.m. On 12/19/10, the resident's blood pressure was obtained at 7:41 p.m., according to the documentation in the facility's weights and vitals summary. Documentation on the MAR indicated [REDACTED] On 12/20/10, the resident's blood pressure was obtained at 4:53 p.m. and 7:12 p.m., according to the documentation on the facility's weights and vitals summary; however, nursing notes written on 12/20/10 stated the resident was out of the facility at [MEDICAL TREATMENT] and did not return to the facility until 6:00 p.m. on 12/20/10. Review of the MAR indicated [REDACTED] On 12/21/10, a nursing note documented the resident's blood pressure was 87/37 when obtained at 10:00 a.m. The resident was sent to the hospital. Further review of the medical record revealed a transfer form to the hospital which documented the reason for the transfer as: BP (blood pressure) 88/37 (symbol for arrow) 80/40 P (pulse) 67. The 12/21/10, a nursing note also documented, . AM (morning) meds. (medications) not given d/t (due to) low BP. Review of the MAR indicated [REDACTED]. There was no evidence the resident's SBP pressure was verified before administering the 6:00 a.m. dose of [MEDICATION NAME]. In an interview with the facility's acting director of nursing on the afternoon of 04/26/11, she verified the resident's blood pressures would be documented in the nursing notes or on the weights and vital summary. She was unable to produce documentation to verify the resident's SBP was consistently obtained as ordered by the physician before administering the above antihypertensive medications at the documented dates and times. She was unable to explain how the resident's blood pressure was obtained at 4:53 p.m. on 12/20/10 when the resident was not at the facility. Multiple antihypertensive medications were administered daily from 12/17/10 through 12/21/10, at numerous times throughout the day, without first verifying the resident's SBP was not less than 110 mmHg, as directed by the resident's physician. The resident was transferred to the hospital for low blood pressure on 12/21/10. -- b) Resident # 94 Medical record review revealed Resident #94, a [AGE] year old female, was receiving [MEDICATION NAME] 10 mg every eight (8) hours, which was ordered on [DATE] for a complaint of neck pain. Review of the resident's list of active [DIAGNOSES REDACTED]. Review of OBRA's Unnecessary Drugs in the Elderly found [MEDICATION NAME] is a muscle relaxant that is poorly tolerated in the elderly due to it strong [MEDICATION NAME] side effects of sedation, weakness, dry mouth, blurred vision, [MEDICAL CONDITION], constipation, confusion, [MEDICAL CONDITION], and hallucinations. Also discovered during this review was that the use of this drug should be used only for a short duration of not greater than seven (7) days. Review of physician progress notes [REDACTED]. Review of the resident's comprehensive care plan, provided by the interim director of nursing (DON - Employee #109) on 04/27/11, found no problem statement addressing the resident's neck pain and the use of [MEDICATION NAME], with monitoring for side effects and the use of non-pharmacological interventions, had been developed. Further interview with the DON confirmed this was the only care plan available. The use of [MEDICATION NAME] (a drug not recommended for long term use in the elderly due to the potential harmful side effects) was not being monitored as required for Resident #94.",2015-11-01
9456,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-28,364,E,0,1,UJUP11,"Based on resident interview, observations, and staff interview, the facility failed to monitor food temperatures at the point of service (in accordance with facility practice) for one (1) of three (3) dining areas, to ensure foods are served at the appropriate temperatures for palatability. This practice had the potential to affect the palatability of foods served to residents who take their meals in the TCU. Facility census: 124. Findings include: a) Interviews conducted with residents who resided on the TCU, on 04/21/11, revealed complaints of receiving cold food. Observation, in the TCU dining area on 04/25/11 at 5:10 p.m., found a dietary aide (Employee #42) preparing to serve residents in the TCU dining room. During this process, the dietary aide was not observed taking temperatures of the food. Interview with the dietary aide, during the food prep, revealed food temperatures were to be taken when the last tray was being prepared. Further observation found the dietary aide served the last tray and stated the food service was completed. It was also observed that no food temperatures had not been taken. Interview with the food service director (Employee #133), on 04/26/11 at 1:00 p.m., revealed it was the facility's practice to measure the temperatures of food items in each of the three (3) dining rooms prior to the end of the meal service, to ensure proper temperatures at the point of service.",2015-11-01
9457,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-28,371,F,0,1,UJUP11,"Based on observation and staff interview, the facility failed to assure food was stored, prepared, and served under sanitary conditions. This deficient practice affected all residents receiving an oral diet. Facility census: 124. Findings include: a) During the initial tour of the dietary department conducted on 04/19/11 at 4:33 p.m., the following unsanitary practices were observed: 1. Upon entrance to the dietary department on 04/19/11 at 4:33 p.m., observation noted dietary personnel were preparing the evening meal. A large, debris-filled garbage can was noted to be placed adjacent to the food preparation area. The garbage can did not have a lid to contain the debris present. 2. Observation found both hand sinks were heavily soiled, and the white plastic trash cans placed adjacent to the hand sinks were heavily soiled on the exterior. 3. The floor of the large walk-in cooler was littered with vegetable debris. A container of ham slices, dated 04/03/11, was located on the floor beneath the cooler shelves. 4. A container of slaw, dated 03/29/11, was found on the shelf of the large walk-in cooler. Also found were bags of cheese sandwiches, peanut and jelly sandwiches, a large container of turkey, a large container of applesauce, a plastic baggy filled with ham chunks, pureed bread, and three (3) containers of potato salad which were either not dated or out-of-date. An interview with the food service director (Employee #133) during these observations confirmed that these were unacceptable sanitation issues. -- b) On 04/27/11 at 4:00 p.m., the following observations were made in the North hall nourishment refrigerator: cartons of ice cream in the freezer, a Styrofoam cup with some type of liquid frozen in it, and green soda bottle were not labeled properly. There was also a large amount of ice in the freezer. On 04/27/11 at 4:20 p.m., an observation was made in the South hall nourishment refrigerator found melted ice cream throughout the freezer, and a red sticky substance was found in the bottom of the refrigerator inside the door. On 04/27/11 at 4:30 p.m., an interview with Employee #133 revealed all items in these refrigerators should be labeled and dated. He further stated the refrigerators should be clean. Employee #133 exited the room and stated he was going immediately to clean both refrigerators. -- c) During dining observations in the TCU dining room on 04/25/11 at 5:30 p.m., the dietary aide (Employee #42) set a pan containing cold foods in a dual compartment sink, and the cook set a red container with a sanitizing solution in the other side of the sink. The dietary aide and other kitchen personnel were then observed washing their hands in this sink which contained the pan of cold foods on one (1) side and the sanitizing solution on the other side. Employee #42 was also observed to put on gloves and prepare trays, placing non-food items on the trays and opening kitchen cabinets, then - without changing gloves - reaching into a container of parsley garnishes and placing them on plates, reaching into the bread bag to place bread on plates, etc. Employee #42 never changed gloves and washed hands between handling / touching non-food items and placing food on trays. During an interview with Employee #133 on 04/26/11 at 1:00 p.m., he confirmed the dietary aide should not have set a pan containing food items in the dish sink where the sanitary solution was and where staff was washing their hands. He also confirmed the dietary aide should have changed gloves and washed hands between handling of food and non-food items.",2015-11-01
9458,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-28,428,D,0,1,UJUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the physician acted upon recommendations by the pharmacist for one (1) of thirty-two (32) Stage II sample residents, with respect to the use of Flexeril with this [AGE] year old resident (which is a muscle relaxant contraindicated for use in the elderly due to its anticholinergic side effects). Resident identifier: #94. Facility census: 124. Findings include: a) Resident #94 1. Medical record review revealed Resident #94, a [AGE] year old female, was receiving Flexeril 10 mg every eight (8) hours, which was ordered on [DATE] for a complaint of neck pain. Review of the resident's list of active [DIAGNOSES REDACTED]. 2. Review of OBRA's Unnecessary Drugs in the Elderly found Flexeril is a muscle relaxant that is poorly tolerated in the elderly due to it strong anticholinergic side effects of sedation, weakness, dry mouth, blurred vision, urinary retention, constipation, confusion, delirium, and hallucinations. Also discovered during this review was that the use of this drug should be used only for a short duration of not greater than seven (7) days. 3. Review of physician progress notes [REDACTED]. 4. Review of the resident's comprehensive care plan, provided by the interim director of nursing (DON - Employee #109) on 04/27/11, found no problem statement addressing the resident's neck pain and the use of Flexeril, with monitoring for side effects and the use of non-pharmacological interventions, had been developed. Further interview with the DON confirmed this was the only care plan available. 5. Review of the pharmacist's monthly drug regimen and report of recommendations to the physician found the pharmacist, on 10/12/10, recommended that a care plan be developed, monitoring for side effects be conducted, and that the physician document an assessment of risk versus benefit, alerting of the potential adverse consequences. This report was signed by the DON on 10/21/10, but no documentation was found indicating the physician had addressed them. Interview with the DON, on 04/28/11 at 2:30 p.m., confirmed these recommendations had not been acted upon by the physician.",2015-11-01
9459,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-28,431,E,0,1,UJUP11,"Based on observation and staff interview, the facility failed to store and label all drugs and biologicals with currently accepted professional principles, as evidenced by staff storing personal beverages in the medication refrigerator on South hall. One (1) of two (2) medication storage room refrigerators was affected. Facility census: 124. Findings include: a) On 04/28/11 at 10:00 a.m., observation of the South hall medication storage room found a Pepsi cola bottle and water bottle in the medication storage refrigerator. The Pepsi cola and water bottle were not labeled. On 04/28/11 at 10:00 a.m., an interview with the licensed practical nurse (LPN - Employee #9) revealed the drinks should not have been in this refrigerator.",2015-11-01
9460,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-28,514,E,0,1,UJUP12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to assure that information recorded in each resident's clinical record was accurate. Record review, at 6:00 p.m. on 06/23/11, found activities of daily living (ADL) sheets (on which nursing assistants documented the service provided to services during each shift) had already been completed for the evening shift, even though this shift was not scheduled to end until 11:00 p.m. The residents were observed to be eating dinner at that time, and the percentage of their meal intake had already been recorded before they were finished. Other important information was also recorded for the entire shift, including the percentage of consumption of the bedtime snacks, bowel movements, amount of assistance provided with each area of care, and the amount of fluids they had consumed that shift. This information was inaccurate for two (2) of twenty-eight (28) sampled residents and five (5) residents of random opportunity, and this practice had the potential to affect more than an isolated number of residents, as this inaccurate information would have been used as the basis for the assessment and treatment of [REDACTED]. Resident identifiers: #34, #27, #64, #45, #118, #95, and #14. Facility census: 128. Findings include: a) Residents #34, #27, #64, #45, #118, #95, and #14 During the evening meal on 06/24/11 at 6:00 p.m., observation found sampled Residents #35 and #27 had received their dinner trays and were eating at that time. The ADL books, when reviewed at that time, found the nursing assistant had already recorded the percentage of meal intake for these residents, even thought they had not completed their meals. The ADL sheets for other residents close to this room, when also reviewed, had entries for meal intakes even though they also were not finished eating. Further review of these ADL sheets found the entire shift's worth of documentation had already been recorded, to include important information such as the amount of assistance provided with each ADL, the residents' bowel and bladder elimination (including how many times each was incontinent during that shift and if they had had a bowel movement), the amount of fluids they consumed throughout the entire shift, and the amount of snacks they consumed. Review of the assignment sheet found one (1) nursing assistant was assigned to all of the residents who had their ADL sheets completed at 6:00 p.m. This nursing assistant was observed to be assisting residents with dinner on the hall at that time. The director of nursing (DON), who was made aware of this issue on the evening of 06/24/11, identified the nursing assistant as Employee #100. This employee was immediately called to the DON's office. When the DON questioned Employee #100 about completing her documentation prior to completion of her shift, she told the DON she thought she was filling in the holes that she left during the last 3:00 p.m. to 11:00 p.m. shift she worked. This practice of recording in residents' ADL records prior to the end of the shift, and before the care is given, results in inaccurate information being recorded.",2015-11-01
9461,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2012-11-20,203,D,1,0,UMPL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide a thirty (30) day written notice of discharge and refused to allow the resident to return to the facility after hospitalization . The facility failed to provide advance notice of the discharge, the reason for the discharge, and the right to appeal the decision. This was true for one (1) of three (3) closed records reviewed. Resident identifier: # 129. Facility census: 128. Findings include: a) Resident #129 Resident #129 was a thirty-seven (37) year old individual admitted to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. On 06/28/12, the facility physician determined the resident had capacity to make medical decisions. The social service assessment, completed on 06/28/12, found the resident achieved a score of fifteen (15) on the brief interview for mental status (BIMS) which indicated the resident was cognitively intact. Medical record review found the facility transferred the resident to a local hospital on [DATE] for evaluation of [MEDICAL CONDITION]. The discharge minimum data set (MDS) assessment, with an assessment reference date (ARD) of 07/24/12, found the resident's return to the facility was anticipated; however, the resident did not return to the facility. An interview was conducted with the social worker, Employee #70, and the administrator on 11/19/12 at 3:00 p.m. The administrator stated the resident's behavior made him a danger to himself and the facility did not want to take the resident back from the hospital. The administrator explained that the staff and the nurse practitioner felt the family members were bringing in drugs to the resident, since pills were found on the resident's floor on two (2) separate occasions. She was concerned the resident would overdose on medication being brought into the facility by family members. Further review of the medical record found a nurse practitioner's notes on 07/23/12, NP (nurse practitioner) found a light green, rectangle shaped pill in the floor beside resident's bed. The pill is a [MEDICATION NAME], but we do not have any like it here at (name of nursing home). On 07/20/12, a nurse found a pill in the resident's cigarette pack, a green long bar looking pill. On 07/20/12, the physician ordered a toxicology screen panel due to discovering medication in the resident's possession. The toxicology screen was positive for benzodiazepines and opiates. Review of the Medication Administration Record [REDACTED]. During an interview with the director of nursing (DON) and the administrator, on 11/19/12 at 3:35 p.m., the DON verified the toxicology report did not prove the resident was taking extra medication. She stated, We would need a level for that and we do not have one. Review of the 07/24/12 admission summary of the admitting hospital found the resident was admitted to the hospital for right lobe pneumonia, acute [MEDICAL CONDITION], urinary tract infection, and metabolic [MEDICAL CONDITION]. Further review of the discharge summary from the admitting hospital, dated 08/01/12 found, . Arrangements have been made for him to go to a (name of facility and location) as the patient was not able to return to (name of discharging nursing home) with questionable concern that his family was bringing in narcotics into the patient, potentially compromising his health as well as his care at the facility. He is aware and does know why the move has to take place and though he is not happy, but does understand why he has to be transferred to this facility outside the area with strict visitation rights. The social services director, Employee #70, was interviewed on 11/20/12 at 1:30 p.m. The social worker was unable to provide any documentation of discussions with the resident, who had capacity, regarding the allegations of family members bringing in medications to the resident at the facility. She verified she did not have any documentation about the resident during his stay at the facility. Review of the facility's policy and procedure for discharge and transfer found: . All patients will receive a notice of transfer or discharge or discharge or discharge transition plan whenever a voluntary or involuntary transfer / discharge occurs. The timing of notifications will be based on state and federal regulations. Patients and / or legal representatives will be provided proper notice in accordance with state and federal regulations should a transfer or discharge be initiated by a (name of the company healthcare center). The administrator was interviewed again on 11/19/12 at 4:10 p.m. regarding the facility's refusal to allow the resident to return to the facility. She was unable to provide documentation from the physician the resident's discharge was necessary and was unable to provide any evidence the resident was actually taking medication supplied by family members. She verified the written information required for a discharge, as required by the regulations was not given to the resident. She stated she had planned on giving the resident a thirty day (30) notice of discharge, but he went to the hospital before she could provide the information. The administrator also verified the facility did have beds available but chose not to allow the resident to return to the facility.",2015-11-01
9462,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2012-11-20,205,E,1,0,UMPL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's discharge policy, and staff interview, the facility failed to ensure transferred / discharged residents / responsible parties received written notice of the bed hold policy at the time of transfer. This was true for three (3) of three (3) residents reviewed who were transferred / discharged to the hospital. Resident identifiers: # 129, # 131, and # 132. Facility census: 128. Findings include: a) Resident # 129 Medical record review found the resident was admitted to a local hospital on [DATE]. b) Resident # 131 Medical record review found the resident was admitted to a local hospital on [DATE]. c) Resident #132 Medical record review found the resident was admitted to the hospital on [DATE]. At 4:10 p.m. on 11/19/12 the director of nursing, Employee #4 and the administrator, Employee #103 provided a copy of the information to be sent with the resident upon transfer or discharge from the facility. Included in the packet was the facility's bed-hold policy. Neither employee was able to provide verification a copy of the bed-hold agreement had beengiven to the resident / responsible party at the time of transfer. Review of the facility's policy and procedure entitled, Discharge and Transfer found: . For patients transferred to a hospital: 5.1 For unplanned, acute transfers, patients, family and legal guardian will be notified verbally. 5.1.1 Written notice will follow verbal notification per state requirements. 5.1.2 A copy of the written notice of transfer will be placed in the patients medical record.",2015-11-01
9463,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2012-11-20,206,D,1,0,UMPL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's bed hold policy, and staff interview, the facility failed to allow a resident, who wanted to return to the facility, re-admission after hospitalization when the facility had empty beds available. This was true for one (1) of three (3) closed records reviewed. Resident identifier: # 129. Facility census: 128. Findings include: a) Resident #129 Resident #129 was a thirty-seven (37) year individual admitted to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. On 06/28/12, the facility physician determined the resident had capacity to make medical decisions. The social service assessment, completed on 06/28/12, found the resident achieved a score of fifteen (15) on the brief interview for mental status (BIMS) which indicated the resident was cognitively intact. Medical record review found the facility transferred the resident to a local hospital on [DATE] for evaluation of [MEDICAL CONDITION]. The discharge minimum data set (MDS) assessment, with an assessment reference date (ARD) of 07/24/12, found the resident's return to the facility was anticipated; however, the resident did not return to the facility. An interview was conducted with the social worker, Employee # 70, and the administrator on 11/19/12 at 3:00 p.m. The administrator stated the resident's behavior made him a danger to himself and the facility did not want to take the resident back from the hospital. The administrator explained the staff and the nurse practitioner had felt the family members were bringing in drugs to the resident, since pills were found on the resident's floor on two (2) separate occasions. She was concerned the resident would overdose on medication being brought into the facility by family members. Further review of the medical record found a nurse practitioner's notes on 07/23/12, NP (nurse practitioner) found a light green, rectangle shaped pill in the floor beside resident's bed. The pill is a [MEDICATION NAME], but we do not have any like it here at (name of nursing home). On 07/20/12, a nurse found a pill in the resident's cigarette pack, a green long bar looking pill. On 07/20/12, the physician ordered a toxicology screen panel due to discovering medication in the resident's possession. The toxicology screen was positive for benzodiazepines and opiates. Review of the Medication Administration Record [REDACTED]. During an interview with the director of nursing (DON) and the administrator, on 11/19/12 at 3:35 p.m., the DON verified the toxicology report did not prove the resident was taking extra medication and she stated, We would need a level for that and we do not have one. Review of the admission summary of the admitting hospital on [DATE] found the resident was admitted to the hospital for right lobe pneumonia, acute [MEDICAL CONDITION], urinary tract infection, and metabolic [MEDICAL CONDITION]. Further review of the discharge summary from the admitting hospital, dated 08/01/12 found, . Arrangements have been made for him to go to a (name of facility and location) as the patient was not able to return to (name of discharging nursing home) with questionable concern that his family was bringing in narcotics into the patient, potentially compromising his health as well as his care at the facility. He is aware and does know why the move has to take place and though he is not happy, but does understand why he has to be transferred to this facility outside the area with strict visitation rights. The social services director, Employee #70 was interviewed on 11/20/12 at 1:30 p.m. The social worker was unable to provide any documentation of discussions with the resident, who had capacity, regarding the allegations of family members bringing in medications to the resident at the facility. She verified she did not have any documentation about the resident during his stay at the facility. Review of the facility's bed hold policy found: In the event that the resident is absent from the facility for more than twenty-four (24) hours, bed reservation privileges are available, if the facility's occupancy rate is greater than 95% and there is a waiting list for admission,. The maximum reimbursement by Medicaid will be twelve (12) days annually for medical leave and six (6) days for therapeutic leave. Placement is to be in the same bed and living space occupied by the resident prior to the hospital or therapeutic leave unless the resident's physical condition upon returning to the facility prohibits access to the bed previously occupied. If the bed is not held the resident will be placed on the facility referral list and readmitted to the facility immediately upon the first availability of a bed in a semi-private room providing the resident requires the services provided by the facility. Review of the daily census report found the facility had five (5) empty beds on the date of the resident's discharge from the hospital. The administrator was interviewed again on 11/19/12 at 4:10 p.m. regarding the facility's refusal to allow the resident to return to the facility. She stated the resident had a Medicaid bed hold available, but the facility chose not to use the bed hold. She also verified the facility did have a bed available for the resident, but he was not readmitted as the facility felt the resident was a danger to himself.",2015-11-01
9464,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2012-11-20,514,E,1,0,UMPL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, medical record review, and closed record review, the facility failed to maintain a complete and accurate medical record in the areas of documentation on medication administration records, treatment records, and activities of daily living flow records. Three (3) of three (3) sampled residents were affected. Resident identifiers: #59, #106, and #129. Facility census: 128. Findings include: a) Resident #59 Resident #59's medical record was reviewed for catheter care. The activities of daily living (ADL) flow record was reviewed for bladder (urinary) output during the months of May, June, July, August, September, October 2012. The following omissions were found on the ADL flow sheet: 05/05/12 11-7 shift 05/15/12 11-7 shift 05/23/12 11-7 shift 06/22/12 7-3 shift 07/25/12 7-3 shift 07/28/12 7-3 shift and 3-11 shift 07/29/12 3-11 shift 07/30/12 3-11 shift 07/31/12 3-11 shift 08/31/12 11-7 shift and 3-11 shift 09/14/12 11-7 shift 09/16/12 3-11 shift 09/19/12 3-11 shift 09/26/12 7-3 shift 10/17/12 7-3 shift 10/30/12 11-7 shift 10/31/12 3-11 shift. b) Resident #106 Resident #106 was admitted to the facility on [DATE]. Medical record review on 11/19/12 revealed the admission orders [REDACTED]. The ADL flow record for November 2012 had the following omission regarding bladder (urinary) output: 11/17/12 3-11 shift. c) Resident #129 Resident #129 was admitted on [DATE] and discharged to the hospital on [DATE]. Resident #129's closed record review on 11/19/12 revealed a physician order [REDACTED]. The medication record for June 2012 had the following omissions regarding the [MEDICAL CONDITION] care: 06/27/12 7a-7p shift 06/29/12 7a-7p shift 06/30/12 7a-7p shift The Medication Administration Record [REDACTED] 07/13/12 7-3 shift and 3-11 shift 07/19/12 3-11 shift 07/22/12 7-3 shift and 3-11 shift 07/23/12 3-11 shift 07/24/12 11-7 shift Resident #129's closed record review on 11/19/12 revealed a physician orders [REDACTED]. The treatment record for June 2012 had the following omissions regarding the catheter care: from 6/20/12 through 6/30/12-7a-7p and 7p-7a shifts. There was no documentation of catheter care for the entire ten (10) days. The ADL flow record for June 2012 had the following omissions regarding bladder (urinary) output: 06/21/12 7-3 shift and 3-11 shift 06/26/12 7-3 shift 06/29/12 3-11 shift The treatment administration record for July 2012 had the following omissions regarding catheter care: 07/23/12 7:00 p.m.-7:00 a.m. shift The ADL flow record for July 2012 had the following omissions regarding bladder (urinary) output: 07/6/12 11-7 shift 07/7/12 7-3 shift 07/11/12 7-3 shift 07/13/12 7-3 shift 07/22/12 7-3 shift and 3-11 shift 07/23/12 11-7 shift and 3-11 shift Employee #103 (the administrator) provided the only policy and procedure for Care of Indwelling Urinary Catheter on 11/19/12. It was verified by interview, on 11/20/12 at 3:00 p.m., with the employee as the only policy available. The policy stated Catheter care will be performed twice a day and PRN (as necessary) and in accordance with a physician's orders [REDACTED]. Empty the catheter drainage bag at least once every eight hours, and as necessary. Report abnormal findings (sediment, irritation around the meatus or decreased urinary output) to nurse or physician. Document: Catheter care, amount of urine output, abnormal findings, if indicated. Employee #103 (administrator) provided the only policy and procedure on [MEDICAL CONDITION] Care on 11/19/12. It was verified by interview on 11/20/12 at 3:00 p.m. with the employee as the only policy available. The procedure stated that [MEDICAL CONDITION] care was to be performed at least BID (twice a day) and PRN (as necessary) as ordered by a physician. Suctioning was a clean technique and changing/cleaning the cannula and/or dressing was a sterile technique, as stated in the procedure.",2015-11-01
9963,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-06-23,514,E,0,1,UJUP12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to assure that information recorded in each resident's clinical record was accurate. Record review, at 6:00 p.m. on 06/23/11, found activities of daily living (ADL) sheets (on which nursing assistants documented the service provided to services during each shift) had already been completed for the evening shift, even though this shift was not scheduled to end until 11:00 p.m. The residents were observed to be eating dinner at that time, and the percentage of their meal intake had already been recorded before they were finished. Other important information was also recorded for the entire shift, including the percentage of consumption of the bedtime snacks, bowel movements, amount of assistance provided with each area of care, and the amount of fluids they had consumed that shift. This information was inaccurate for two (2) of twenty-eight (28) sampled residents and five (5) residents of random opportunity, and this practice had the potential to affect more than an isolated number of residents, as this inaccurate information would have been used as the basis for the assessment and treatment of [REDACTED]. Resident identifiers: #34, #27, #64, #45, #118, #95, and #14. Facility census: 128. Findings include: a) Residents #34, #27, #64, #45, #118, #95, and #14 During the evening meal on 06/24/11 at 6:00 p.m., observation found sampled Residents #35 and #27 had received their dinner trays and were eating at that time. The ADL books, when reviewed at that time, found the nursing assistant had already recorded the percentage of meal intake for these residents, even thought they had not completed their meals. The ADL sheets for other residents close to this room, when also reviewed, had entries for meal intakes even though they also were not finished eating. Further review of these ADL sheets found the entire shift's worth of documentation had already been recorded, to include important information such as the amount of assistance provided with each ADL, the residents' bowel and bladder elimination (including how many times each was incontinent during that shift and if they had had a bowel movement), the amount of fluids they consumed throughout the entire shift, and the amount of snacks they consumed. Review of the assignment sheet found one (1) nursing assistant was assigned to all of the residents who had their ADL sheets completed at 6:00 p.m. This nursing assistant was observed to be assisting residents with dinner on the hall at that time. The director of nursing (DON), who was made aware of this issue on the evening of 06/24/11, identified the nursing assistant as Employee #100. This employee was immediately called to the DON's office. When the DON questioned Employee #100 about completing her documentation prior to completion of her shift, she told the DON she thought she was filling in the ""holes"" that she left during the last 3:00 p.m. to 11:00 p.m. shift she worked. This practice of recording in residents' ADL records prior to the end of the shift, and before the care is given, results in inaccurate information being recorded.",2015-08-01
10677,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-09-28,323,E,1,0,G2W911,". Based on observation and staff interview, the facility failed to provide supervision to prevent avoidable accidents and to promote resident safety, as evidenced by staff leaving a medication cart in the hallway unlocked and unattended. This deficient practice has the potential to affect more than an isolated number of residents. Facility census: 126. Findings include: a) Observation, on 09/27/11 at 9:21 a.m., found a medication cart unlocked and unattended by staff. The door to the resident rooms were closed. The nurse responsible for the medication cart could not be found. Interview with Employee #49 (a licensed practical nurse), at 9:30 a.m., confirmed she had left the cart unlocked and unattended while she was in the room with a resident with the door closed. .",2015-01-01
10678,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-09-28,328,D,1,0,G2W911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to ensure residents received oxygen therapy as ordered by the physician for two (2) of fifteen (15) sampled residents. Resident identifiers: #36 and #74. Facility census: 126. Findings include: a) Resident #36 During random observations of residents, on 09/26/11 at 3:45 p.m., found Resident #36 in his room with oxygen in use. The flow rate on the oxygen concentrator was set to 3 liters per minute. Resident #36's son was present at the time of the discovery. Review of the medical record revealed Resident #36's oxygen was to be delivered at a rate of 2 liters per minute. This observation was reported to the registered nurse (RN - Employee #42), who stated, ""He's supposed to be on 2 liters not 3."" Employee #42 changed the settings on the concentrator to 2 liters as ordered. Observation, on 09/27/11 at 2:19 p.m., found Resident #36 with the nasal cannula in place, but the oxygen concentrator was not running. This observation was reported to an assistant director of nursing (ADON - Employee #90) at 2:19 p.m., who stated, ""It's out of oxygen."" -- b) Resident #74 Observation, on 09/26/11 at 3:00 p.m., found Resident #74 in her room with her oxygen concentrator running, but the nasal cannula was lying in her bed. A nursing assistant was observed in the room at that time. A repeat observation at 3:15 p.m. found Resident #74 with her nasal cannula in place and the flow rate of the oxygen concentrator running at 5 liters per minute. Resident #74's nurse, a licensed practical nurse from a temporary staffing agency (Employee #146) was asked how much oxygen the resident was to be receiving. She stated, ""It's supposed to be on 3 liters."" Review of Resident #74's medical record found a physician's orders [REDACTED]. Employee #146 returned to this surveyor later in the day and stated, ""I read her chart and she is supposed to be on 2 liters not 3. I don't take care of her a lot."" .",2015-01-01
10679,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-09-28,246,D,1,0,G2W911,". Based on observation, resident comments, and staff interview, the facility failed to ensure water was readily available and easily accessible to one (1) resident of random opportunity. Resident identifier: #5. Facility census: 126. Findings include: a) Resident #5 During random observations of residents, on 09/27/11, found Resident #5 hollering for a nurse. This surveyor entered the room and noted the resident's water pitcher was located on her overbed table, which was at the foot of her bed. The resident asked the surveyor to move her overbed table so she could reach it, stating, ""I want a drink of water."" The water pitcher was empty. This observation was immediately reported to the registered nurse (Employee #42). .",2015-01-01
10820,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-08-17,309,D,1,0,8UE611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of a nursing drug handbook, and staff interview, the facility failed, for one (1) of five (5) residents, to assess / monitor the resident after starting new medication which was known to produce the adverse side effect of decreased level of consciousness. The resident later needed emergency medical treatment after experiencing symptoms of lethargy and a decrease level of consciousness. Resident identifier: #128. Facility census: 126. Findings include: a) Resident #128 Record review revealed this [AGE] year old female, who was admitted to the facility on [DATE], was transported to the local emergency roiagnom on [DATE] and did not return to the facility. Her [DIAGNOSES REDACTED]. She had also received antibiotic treatment for [REDACTED]. diff) - a bacterial infection that may develop after prolonged use of antibiotics during healthcare treatment. - A physician's orders [REDACTED]. In 3 days increase to 20 mg one tab po tid."" - Review of the nursing notes revealed an entry dated 06/29/11 at 17:00 (5:00 p.m.), stating (quoted directly as stated in the electronic medical record): ""Called to resident room by PTA (physical therapy assistant). Stated resident 'doesn't seem right.' Resident noted to be slumped over to the right side in wheelchair. Lethargic but arousable. Oriented to self, but not to place or time. Vital signs stable, afebrile, Blood sugar 145. Resident started flailing arms while myself was in the room. Stated she has been 'blacking out and I don' know where I am.' Resident states that she wants us to send her to the hospital 'to get checked out.' Notified Dr. (name) of residents request. Order received to send to ER for evaluation. Notified residents son per her request of ambulance transport to ER. After calling 911 for transport to hospital, notified by residents son that resident 'wont wake up.' Assessed resident again. Unresponsive. BP 90/68, HR 58 Resp 14. Remained with resident until (ambulance service) arrived."" An earlier nursing note, dated 06/29/11 at 13:35 (1:35 p.m.), stated (quoted directly as stated in the electronic medical record): ""Skilled nursing: therapy/teaching/training: Management/Evaluation; Nrsg Obsrvtn: Skilled for PT (physical therapy) and OT (occupational therapy) related to reconditioning, therapy, [MEDICAL CONDITIONS]. Observations: At beginning of shift resident complained of dizziness, which is not unusual for her. It was noted that she was not using her oxygen, her nasal cannular was lying beside her on the bed. She indicated that she had removed it. He oxygen sat. was 90% and immediately went to 92% when oxygen was given. Resident was cautioned to continue to use her oxygen. She stated that she felt better after oxygen was re administered. BP 123/72 Temperature 96.7 orally Pulse 90 and Respirations 20. NO respiratory distress noted. Resident denies pain. CBC and BMP lab result returned today and reviewed with facility doctor. No new orders at this time. Will continue to monitor resident."" - According to Lexi-Comp's Drug Information Handbook for Nursing (8th edition), [MEDICATION NAME] is a skeletal muscle relaxant which produces the following adverse reactions in greater than 10% of its users: ""Central nervous system: Drowsiness, [MEDICAL CONDITION], psychiatric disturbances, [MEDICAL CONDITION], slurred speech, ataxia (lack of muscle coordination during voluntary movements), [DIAGNOSES REDACTED] (low muscle tone which can affect muscle strength). Neuromuscular & skeletal: Weakness."" In 1% to 10% of the users, it produces the following adverse reactions: ""Cardiovascular: [MEDICAL CONDITION]. Central nervous system: Fatigue, confusion, headache. Dermatologic: Rash. Gastrologic: Nausea, constipation. [MEDICAL CONDITION]: Polyuria (excessive urination)."" The following nursing actions are recommended when administering [MEDICATION NAME]: ""Physical Assessment: Assess effectiveness and interactions of other medications patient may be taking. Monitor effectiveness of therapy (according to rational (sic) for therapy) and adverse reactions (e.g., cardiovascular and CNS (central nervous system) status at beginning of therapy and periodically with long-term use. ..."" Under the heading ""Geriatric Considerations"" was found: ""The elderly are more sensitive to the effects of [MEDICATION NAME] and are more likely to experience adverse CNS side effects at higher doses. Two cases of [MEDICAL CONDITION] were reported after inadvertent high doses (50 mg/day and 90 mg/day) were given to elderly patients."" - A review of the Medication Administration Record [REDACTED]. Review of the nursing notes found no evidence of any monitoring of the resident's reaction to the new medication after she began receiving the [MEDICATION NAME] 5 mg tid on 06/25/11. This lack of monitoring continued, and the facility increased the [MEDICATION NAME] to 20 mg tid on 06/28/11. After receiving two (2) doses of the [MEDICATION NAME] 20 mg (one (1) on 06/28/11 at 9:00 p.m. and the other on 06/29/11 at 9:00 a.m.), the resident began experiencing signs of confusion and told the staff she did not know where she was and felt she had blacked out. Before transport to a local hospital, the resident became non-responsive. - Employee #93 (the interim director of nursing) and Employee #95 (a registered nurse) both reviewed the resident's medical record on the afternoon of 08/16/11 and did not locate any documentation to show the facility had monitored the resident's physical and mental functioning after the start of this new medication. .",2014-12-01
10821,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-08-17,312,D,1,0,8UE611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, medical record review, and staff interview, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary care and services to maintain good grooming and personal hygiene. Two (2) of eleven (11) sampled residents who were dependent on staff for grooming had unmet grooming needs. One (1) resident had long chin hairs that she wanted to have shaved, and the other had long, dirty fingernails that she wanted to have cleaned. Resident identifiers: #57 and #123. Facility census: 126. Findings include: a) Resident #123 During an interview with Resident #123 on 08/16/11 at approximately 11:30 a.m., observation found she had long hair on her chin. She said she normally has the staff shave this hair off. She said the person that normally does this did not work on Saturday or Sunday and she forgot to ask them to do shave her on Friday. This resident was cooperative with care, and there was no indication she had refused to have this facial hair removed. The resident has a [DIAGNOSES REDACTED]. As of 08/16/11 at 5:00 p.m., no one had shaved the resident. The resident's care plan stated she was dependent on staff for activities of daily living (ADLs) related to a recent fracture and history of dementia. The care plan stated she can wash her face, hands, and upper body; however, she was dependent on staff for grooming. -- b) Resident #57 During a tour of the facility on 08/15/11 at approximately 2:00 p.m., observation found Resident #57 had long dirty fingernails. When asked, she said she would like her nails cleaned, but she could not do this on her own. Employee #172 (a licensed practical nurse) said she would assist the resident with cleaning her nails. .",2014-12-01
10822,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-08-17,329,D,1,0,8UE611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of a nursing drug handbook, and staff interview, the facility failed to ensure the medication regimen of one (1) of five (5) sampled residents was free from unnecessary drugs without adequate monitoring and without adequate indication for its use. Resident #128 received the antispastic medication [MEDICATION NAME] for approximately five (5) days before she was transferred to a local emergency department due to lethargy and decreased level of consciousness. The medical record revealed no documentation as to why the resident needed the medication, and there was no evidence to reflect nursing staff was routinely monitoring the resident for common adverse side effects affecting the central nervous system. Resident identifier: #127. Facility census: 126. Findings include: a) Resident #128 Record review revealed this [AGE] year old female, who was admitted to the facility on [DATE], was transported to the local emergency roiagnom on [DATE] and did not return to the facility. Her [DIAGNOSES REDACTED]. She had also received antibiotic treatment for [REDACTED]. diff) - a bacterial infection that may develop after prolonged use of antibiotics during healthcare treatment. - A physician's orders [REDACTED]. In 3 days increase to 20 mg one tab po tid."" - Review of the nursing notes revealed an entry dated 06/29/11 at 17:00 (5:00 p.m.), stating (quoted directly as stated in the electronic medical record): ""Called to resident room by PTA (physical therapy assistant). Stated resident 'doesn't seem right.' Resident noted to be slumped over to the right side in wheelchair. Lethargic but arousable. Oriented to self, but not to place or time. Vital signs stable, afebrile, Blood sugar 145. Resident started flailing arms while myself was in the room. Stated she has been 'blacking out and I don' know where I am.' Resident states that she wants us to send her to the hospital 'to get checked out.' Notified Dr. (name) of residents request. Order received to send to ER for evaluation. Notified residents son per her request of ambulance transport to ER. After calling 911 for transport to hospital, notified by residents son that resident 'wont wake up.' Assessed resident again. Unresponsive. BP 90/68, HR 58 Resp 14. Remained with resident until (ambulance service) arrived."" An earlier nursing note, dated 06/29/11 at 13:35 (1:35 p.m.), stated (quoted directly as stated in the electronic medical record): ""Skilled nursing: therapy/teaching/training: Management/Evaluation; Nrsg Obsrvtn: Skilled for PT (physical therapy) and OT (occupational therapy) related to reconditioning, therapy, [MEDICAL CONDITIONS]. Observations: At beginning of shift resident complained of dizziness, which is not unusual for her. It was noted that she was not using her oxygen, her nasal cannular was lying beside her on the bed. She indicated that she had removed it. He oxygen sat. was 90% and immediately went to 92% when oxygen was given. Resident was cautioned to continue to use her oxygen. She stated that she felt better after oxygen was re administered. BP 123/72 Temperature 96.7 orally Pulse 90 and Respirations 20. NO respiratory distress noted. Resident denies pain. CBC and BMP lab result returned today and reviewed with facility doctor. No new orders at this time. Will continue to monitor resident."" - On 06/29/11 (the date of discharge to the hospital), the nurse practitioner (Employee #173) typed a discharge note which stated: ""Course in facility (narrative) ""95 y/o (year old) while, widowed female admitted to Valley Center on 06/01/2011 for rehabilitation due to deconditioning s/p marked [MEDICAL CONDITION] due to GI (gastrointestinal) bleed requiring transfusion. PMH (past medical history): dizziness/body weakness with + occult blood, [MEDICAL CONDITIONS](hypertension), [MEDICAL CONDITIONS],[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease), [DIAGNOSES REDACTED], joint disease. No h (history) of tobacco abuse, no ETOH (alcohol) abuse. Family hx (history) is non-contributory. Res transferred to Hospital Emergency Dept d/t severe lethargy. ""Exam ""vs (vital signs) stable resident difficult to arouse. Pupils PEARL (pupils equal and reactive to light). Heart regular grade II/VI systolic murmur. Lungs CTAB (clear to auscultation bilaterally). ""Medications on discharge ""[MEDICATION NAME] 20 mg po tid d/t bladder spasms .... "" Nowhere else in the medical record, prior to the resident's discharge to the hospital, was there any mention of the resident experiencing bladder spasms. - According to Lexi-Comp's Drug Information Handbook for Nursing (8th edition), [MEDICATION NAME] is a skeletal muscle relaxant which produces the following adverse reactions in greater than 10% of its users: ""Central nervous system: Drowsiness, [MEDICAL CONDITION], psychiatric disturbances, [MEDICAL CONDITION], slurred speech, ataxia (lack of muscle coordination during voluntary movements), [DIAGNOSES REDACTED] (low muscle tone which can affect muscle strength). Neuromuscular & skeletal: Weakness."" In 1% to 10% of the users, it produces the following adverse reactions: ""Cardiovascular: [MEDICAL CONDITION]. Central nervous system: Fatigue, confusion, headache. Dermatologic: Rash. Gastrologic: Nausea, constipation. [MEDICAL CONDITION]: Polyuria (excessive urination)."" The following nursing actions are recommended when administering [MEDICATION NAME]: ""Physical Assessment: Assess effectiveness and interactions of other medications patient may be taking. Monitor effectiveness of therapy (according to rational (sic) for therapy) and adverse reactions (e.g., cardiovascular and CNS (central nervous system) status at beginning of therapy and periodically with long-term use. ..."" Under the heading ""Geriatric Considerations"" was found: ""The elderly are more sensitive to the effects of [MEDICATION NAME] and are more likely to experience adverse CNS side effects at higher doses. Two cases of [MEDICAL CONDITION] were reported after inadvertent high doses (50 mg/day and 90 mg/day) were given to elderly patients."" - A review of the Medication Administration Record [REDACTED]. Review of the nursing notes found no evidence of any monitoring of the resident's reaction to the new medication after she began receiving the [MEDICATION NAME] 5 mg tid on 06/25/11. This lack of monitoring continued, and the facility increased the [MEDICATION NAME] to 20 mg tid on 06/28/11. After receiving two (2) doses of the [MEDICATION NAME] 20 mg (one (1) on 06/28/11 at 9:00 p.m. and the other on 06/29/11 at 9:00 a.m.), the resident began experiencing signs of confusion and told the staff she did not know where she was and felt she had blacked out. Before transport to a local hospital, the resident became non-responsive. - Employee #93 (the interim director of nursing) and Employee #95 (a registered nurse) both reviewed the resident's medical record on the afternoon of 08/16/11 and did not locate any documentation to show the facility had monitored the resident's physical and mental functioning after the start of this new medication. Employee #93 also did not locate any documentation reflecting Resident #128 had experienced signs and symptoms of bladder spasms prior to receiving the [MEDICATION NAME]. The only reference to [MEDICATION NAME] being used to treat bladder spasms came in the discharge note prepared on 06/29/11, five (5) days after Resident #128 began receiving the medication. - The medical record revealed there were no pharmacy reviews scheduled during the time the resident received this medication. The medical record also revealed no documentation from any clinical staff, physician, or nurse practitioner prior to the resident's transfer to the hospital regarding the need for this medication.",2014-12-01
11048,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,152,E,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed, for four (4) of twenty-eight (28) sampled records, to ensure legal surrogates were designated in accordance with State law for residents who have been determined to lack the capacity to understand and make their own health care decisions. Additionally, the facility failed to ensure the correct legal surrogate was identified in the medical record and contacted when health care decisions needed to be made. Resident identifiers: #3, #113, #131, and #19. Facility census: 128. Findings include: a) Resident #3 Medical record review, completed on 06/24/09, revealed the face sheet (demographic sheet) identified the resident's son was his medical power of attorney representative (MPOA). Review of the resident's MPOA document revealed the wife was the primary MPOA and the son was the successor MPOA. Further review revealed, on 11/19/08, the facility sent a notice to the resident's son, informing him of an upcoming care plan meeting. When interviewed on 06/24/09 at 11:20 a.m., the social worker (Employee #22) identified that the correct legal representative was the wife and the medical record face sheet was incorrect. Shortly after this interview, the face sheet was corrected. b) Resident #113 Medical record review, on 06/23/09, revealed Resident #113 was determined by his physician to lack capacity to make an informed choice regarding medical decisions on 03/27/09. Documentation on the form entitled ""Physician Determination of Capacity"" stated the resident lacked capacity due to a ""[MEDICAL CONDITION]"" ([MEDICAL CONDITION] - stroke). The determination of incapacity was based solely on a medical condition and did not provide information to describe what components of the disease interfered with his ability to understand and make informed health care decisions. The facility's director of nursing (DON - Employee #82), when provided this information on 06/25/09, was unable to provide any additional documentation by the resident's physician to describe the nature of the resident's incapacity. c) Resident #131 Closed medical record review, on 06/25/09, revealed Resident #131 was determined by his physician to lack capacity to make an informed choice regarding medical decisions on 02/27/09. Documentation on the form entitled ""Physician Determination of Capacity"" stated the resident lacked capacity due to the [DIAGNOSES REDACTED]. The determination of incapacity was based solely on a medical condition and did not provide information to describe what components of the disease interfered with his ability to understand and make informed health care decisions. The DON,when provided this information on 06/25/09, was unable to provide any additional documentation by the resident's physician to describe the nature of the resident's incapacity. d) Resident #19 Medical record review for Resident #19 revealed the physician's determination of capacity stated Resident #19 demonstrated incapacity to understand and make informed medical decisions and indicated, with a check mark, the [DIAGNOSES REDACTED]. There was NO further information regarding cause or nature, as required by State law. During an interview with the social worker (Employee #128) at 11:00 a.m. on 06/24/09, he confirmed the physician had not filled in all the required information on the determination of capacity form. e) Per W.Va. Code 16-30-7. Determination of incapacity: ""(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. ""(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ""(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. .",2014-09-01
11049,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,253,E,0,1,OJEL11,"Based on observation and staff interview, the facility failed to provide effective housekeeping and maintenance services to ensure a clean, comfortable, homelike environment for two (2) of three (3) halls observed. Walls were observed to be dirty, and walls and doors were in need of repair and paint. Bathroom toilets were leaking at the tank and around the base, and two (2) toilets were noted to have towels placed at their bases to catch dripping water. Bathroom sinks were observed to have dripping faucets. These deficient practices affected more than an isolated number of residents. Facility census: 128. Findings include: a) Observations of the front entrance and 100 hall 1. On 06/24/09 at 9:10 a.m., observations of the front entrance to the building and the 100 hall revealed the following: - The front foyer was observed to have a dirty floor, especially around a metal plate covering a opening to drain system. - The public women's restroom was observed to have cracked and stained caulk at the bottom of the toilet, which was malodorous. - The 100 hall corridor was observed to be stained, with built-up dirt in cracks and along the cove base. 2. Observations of individual rooms on 100 hall revealed the following: - Room 102 - bathroom door was scratched up and did not close properly. - Room 104 - sink in the bathroom was dripping, floor stained, toilet running, spackling on the wall not sanded or painted, and noticeably dirty. - Room 105 - bathroom sink dripping, base of toilet had cracked and stained caulking, floor stained, bathroom was malodorous. - Room 106 - wall behind bed where new light had been installed needed to be patched and painted. - Room 107 - bathroom sink dripping, towel placed behind toilet bowl catching leaking water. - Room 109 - resident room dirty with visible dirt / debris along the cove base, bathroom sink dripping, base of toilet had stained and cracked caulking, bathroom was malodorous. - Room 110 - toilet running continuously, which did not stop with movement of the toilet handle. - Room 116 - bathroom sink dripping, bathroom wall chipped and cracked - Room 117 - bathroom sink dripping and bathroom door chipped and scratched up. - Room 119 - toilet running continuously, which did not stop with movement of the toilet handle. - Room 120 - resident room dirty with dirt and debris along the cove base - Room 121 - bathroom sink dripping - Room 123 - bathroom cover base missing. - Room 125 - bathroom sink dripping. 3. On the afternoon of 06/25/09, the director of nursing (DON - Employee #82), when interviewed, acknowledged they were aware of the environmental issues with the building and were in the process of taking corrective action. b) Observations of 300 hall 1. During the initial tour of the facility on 06/22/09, and during subsequent tours of the facility, the following observations were made on the 300 hall: - On 06/22/09 at 3:00 p.m., observation of the central shower room on the 300 hall found the commode was full of feces, there was a fecal smear on the floor, and a wet towel was also laying in the floor. At 4:30 p.m., repeat observations of the shower room found it unchanged. A facility nurse (Employee #86), when asked to observe the room, confirmed the findings. - On 06/24/09 at 11:00 a.m., Room #311 had chips and tears in the dry wall. - Room 312 - food particles in the top of the air conditioning unit and the baseboards had crusty build-up in the corners of the room. - Room 314 - had a dirty air conditioning unit, with dust and debris in the top of it. - Room 315 - had dirty floors in the bathroom, the floor tile was brown around the walls of the bathroom, and the commode had several layers of caulking at its base. - Room 316 - had walls at the bathroom entrance that were deeply scuffed and chipped. - Room 317 - had walls at the bathroom entrance that were deeply scuffed and chipped - Room 321 - was noted to have deep scuffs in the dry wall; the wall at the bathroom entrance was scuffed and in need of painting. Around the base of the commode were several layers of caulking, and the corners of the bathroom tile were brown and discolored. - Room 318 - had dirty floors, and the commode had several layers of caulking at its base. - Room 319 - had scuffs and tears in the dry wall, and the bathroom commode had several layers of caulking at its base. - Room 320 - had damage to the walls, scuffing and tears in the drywall, the baseboards at the corners of the room were dirty with crusted materials, the air conditioning unit had debris in the top of it. - Rooms 301 and 303 - had dirty air conditioning units with dust and debris in the top. 2. Several of these findings were bought to the attention of the DON at the time of these observations. The DON confirmed the scuffed walls, dirty air conditioning units, and layers of caulking at the base of the commodes. .",2014-09-01
11050,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,272,E,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the Long Term Care News Safety Alert January 2005 issued by the State survey and certification agency, review of the [MEDICATION NAME] low air loss mattress manufacturer's operating manual, and staff interview, the facility failed, for ten (10) of twenty-eight (28) sampled residents, to complete bed safety assessments for residents using a speciality mattress in conjunction with side rails, in order to identify and mitigate bed safety hazards. Resident identifiers: #4, #33, #43, #51, #66, #84, #103, #104, #114, and #129. Facility census: 128. Findings include: a) Observation Initial tour of the facility, on 06/22/09 at 2:30 p.m., revealed the facility had in use several speciality air beds. Further investigation revealed the [MEDICATION NAME] low air loss mattress systems in use were owned (not rented) by the facility. --- b) Safety Alert In January 2005, the State survey and certification agency issued to all WV Medicare / Medicaid certified nursing facilities and licensed nursing homes a Safety Alert regarding bed safety and entrapment hazards, which contained the following: ""... It is highly recommended that all licensed nursing homes and/or Medicare / Medicaid certified nursing facilities immediately inspect all beds to identify areas of possible entrapment and take immediate action to reduce the risk of entrapment. ""In 1995, the U.S. Food and Drug Administration (FDA) issued a Safety Alert entitled 'Entrapment Hazards with Hospital Bed Side Rails' to several groups of health care providers, including all nursing homes and hospital administrators. In this Alert, the FDA made the following recommendation: 'Inspect all hospital bed frames, bed side rails, and mattresses as part of a regular maintenance program to identify areas of possible entrapment. Regardless of the mattress width, length, and/or depth, alignment to the bed frame, bed side rail, and mattress should leave no gap wide enough to entrap a patient's head or body. Be aware that gaps can be created by movement or compression of the mattress which may be caused by patient weight, patient movement, or bed position...' ""The Alert also reminded providers of their responsibility under the Safe Medical Devices Act of 1990, which requires hospitals and other user facilities to report deaths, serious illness, and injuries associated with the use of medical devices, including bed rails."" -- The State survey and certification agency's 2005 Safety Alert also contained the following: ""In April 2003, the Hospital Bed Safety Workgroup published Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings. ""Suggested Bed Rail Safety Guidelines are as follows: "" 'If it is determined that bed rails are required and that other environmental or treatment considerations may not meet the individual patient ' s assessed needs, or have been tried and were unsuccessful in meeting the patient ' s assessed needs, then close attention must be given to the design of the rail and the relationship between rails and other parts of the bed. 1. The bars within the bed rails should be closely spaced to prevent a patient ' s head from passing through the openings and becoming entrapped. 2. The mattress to bed rail interface should prevent an individual from falling between the mattress and bed rails and possibly smothering. 3. Care should be taken that the mattress does not shrink over time or after cleaning. Such shrinkage increases the potential space between the rails and the mattress. 4. Check for compression of the mattress's outside perimeter. Easily compressed perimeters can increase the gaps between the mattress and the bed rail. 5. Ensure that the mattress is appropriately sized for the selected bed frame, as not all beds and mattresses are interchangeable. 6. The space between the bed rails and the mattress and the headboard and the mattress should be filled either by an added firm inlay or a mattress that creates an interface with the beds rail that prevents an individual from falling between the mattress and bed rails. 7. Latches securing bed rails should be stable so that the bed rails will not fall when shaken. 8. Older bed rail designs that have tapered or winged ends are not appropriate for use with patients assessed to be at risk for entrapment. 9. Maintenance and monitoring of the bed, mattress, and accessories such as patient / caregiver assist items should be ongoing.' "" --- c) In an interview, the director of nursing (DON - Employee #82) reported the [MEDICATION NAME] low air loss mattress manufacturer's operating manual identified that side rails must be used with this mattress. Employee #73 produced a copy of this operating manual to the survey team on 06/25/09. Review of the manual revealed: ""[MEDICATION NAME] mattresses are not intended to be AND DO NOT FUNCTION AS a patient fall safety device. SIDE RAILS MUST BE USED WITH THE [MEDICATION NAME] MATTRESS TO HELP PREVENT FALLS, unless determined unnecessary based on the facility protocol or the patient's medical needs as determined by the facility, IN THESE CASES THE USE OF OTHER SUITABLE PATIENT SAFETY MEASURES ARE RECOMMENDED."" The facility failed to complete individualized assessments for each resident using a [MEDICATION NAME] mattress to identify potential bed safety hazards and/or needs. .",2014-09-01
11051,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,309,E,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to provide the necessary care and services to each resident, to assist them in attaining or maintaining the highest practicable physical well-being, by failing to obtain physicians' orders to define the parameters of use of specialty mattresses and/or side rails and failing to carry out a physician's order reducing the dosage of a medication. This affected four (4) of twenty-eight (28) sampled residents. Resident identifiers: #84, #129, #114, and #15. Facility census: 128. Findings include: a) Resident #84 During the general tour of the facility at 2:30 p.m. on 06/22/09, observation found Resident #84 in bed resting on [MEDICATION NAME] low air loss mattress with controls that allowed for different settings of firmness. Review of her care plan revealed an intervention, under the problem of wound care, for: ""Pressure redistribution surfaces to bed."" However, there was no evidence in Resident #84's record of a physician's order for use of this mattress or of the settings to be used. During an interview at 1:15 p.m. on 06/25/09, the director of nursing (DON - Employee #82) acknowledged the facility failed to obtain a physician's order for use of the specialty mattress and assumed the nurses were using the same settings that were being used for other residents. b) Resident #129 Medical record review, on 06/25/09, revealed Resident #129 was using a [MEDICATION NAME] mattress (for an alteration in skin integrity) in conjunction with side rails. Further review revealed there was no physician's order for the mattress or the side rails, and the facility did not complete a bed safety assessment or a side rail use assessment prior to implementing these interventions. (See also citation at F272.) c) Resident #114 Observation, at 11:00 a.m. on 06/25/09, revealed this resident was lying on a low air mattress which had a raised border surrounding it. The resident also had raised half (1/2) side rails. Review of the resident's current physicians' orders revealed no order for this mattress or the side rails. Further review revealed the mattress (Stat 4000 Multizone Mattress coverlay with settings Float Mode: 4.0, 5.5, 6.0, 5.0,3.5, 1.5) had originally been ordered on [DATE], but the order had not been carried forward to the resident's current orders. d) Resident #15 Review of Resident #15's medical record, on 06/23/09, disclosed a ""Consultation Report"" completed by the facility's contracted pharmacist consultant. This document, dated as completed on 10/28/08, recommended to the physician that the continued use of Nerium 40 mg daily to exceed twelve (12) weeks should be accompanied by a documented rationale for continued use. The DON had written a message to the physician on the bottom of the form asking to change the dose of Nerium to 20 mg daily. On 11/28/08, the resident's attending physician addressed the recommendation by stating ""as below"". According to the DON, when questioned on 06/23/09 at 11:00 a.m., this statement indicated he would like to change the order to Nerium 20 mg daily. Further review of the resident's current medical regimen disclosed this order had never been carried out by facility staff. The resident continued to receive Nerium 40 mg daily. .",2014-09-01
11052,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,329,D,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of medication formularies, and staff interview, the facility failed to ensure each resident's medication regimen was free from unnecessary drugs given without adequate indications for use. Resident #35 was given a hypnotic (Ambien) without an assessment of possible causes for the sleeplessness and without first attempting the use of non-pharmacologic interventions to reduce or prevent the target behaviors prior to medicating the resident. Resident identifiers: #35. Facility census: 128. Findings include: a) Resident #35 1. Medical record review, on 06/23/09, revealed the physician [MEDICATION NAME](an hypnotic) on 03/10/09. Review of the nursing progress for 03/10/09 found documentation to indicate Resident #35 had exhibited increased agitation and was not sleeping at night. Further record review failed find when these behaviors were initially observed, nor did the record contain any assessments in an attempt to identify possible causal or contributing factors to the increased agitation and decreased ability to sleep at night. Additionally, the medical record contained no evidence of any non-pharmacologic interventions that had been attempted without success to reduce or prevent the agitation and difficulty sleeping, prior to institution of the hypnotic (Ambien). 2. According to http://www.rxlist.com/ambien-drug.htm: ""Ambien ([MEDICATION NAME]) is indicated for the short-term treatment of [REDACTED].[MEDICATION NAME] been shown to decrease sleep latency for up to 35 days in controlled clinical studies. This medication is usually limited to short-term treatment periods of 1-2 weeks or less. ""Because sleep disturbances may be the presenting manifestation of a physical and/or psychiatric disorder, symptomatic treatment of [REDACTED]. The failure of [MEDICAL CONDITION] to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated. ""Use in the elderly and/or debilitated patients: Impaired motor and/or cognitive performance after repeated exposure or unusual sensitivity to sedative/hypnotic drugs is a concern in the treatment of [REDACTED]. Therefore, the [MEDICATION NAME] is 5 mg in such patients to decrease the possibility of side effects. These patients should be closely monitored."" 3. On 06/25/09, the director of nursing (DON - Employee #82), when interviewed concerning this resident, identified the facility had been providing education to nursing staff on other psychoactive medications, but they needed to take a closer look at the use of hypnotics in relationship to non-pharmacologic interventions tried prior to initiation of medications. .",2014-09-01
11053,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,502,D,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's lab monitoring protocol, and staff interview, the facility failed to obtain routine lab studies for one (1) of twenty-five (25) sampled residents with a [DIAGNOSES REDACTED].#35. Facility census: 128. Findings include: a) Resident #35 Medical record review, on 06/23/09, revealed Resident #35 was a diabetic. Review of the laboratory testing completed revealed a Hemoglobin A1c completed in November 2008. According to the facility's lab monitoring protocol for diabetic therapy, Hemoglobin A1c is to be completed every four (4) months. Review of the resident's monthly recapitulation of physician orders [REDACTED]. On the afternoon of 06/25/09, the facility's director of nursing (DON - Employee #82), when interviewed, identified this resident had been in and out of the hospital during this period and the Hemoglobin A1c could have been due when she was in the hospital. Prior to survey exit, no additional information was provided regarding this concern. .",2014-09-01
11054,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,386,E,0,1,OJEL11,"Based on medical record review and staff interview, the facility failed to ensure the attending physician, for four (4) of twenty-eight (28) sampled residents, reviewed the resident's total plan of care with each assessment visit by signing routine and telephone orders. Resident identifiers: #15, #35, #19, and #4. Facility census: 128. Findings include: a) Resident #15 The medical record of Resident #15, when reviewed on 06/23/09, disclosed the resident's attending physician wrote a progress note describing a regular assessment visit for this resident on 05/29/09. Further review disclosed the physician had failed to sign telephone orders given to facility staff on 01/10/09, 01/29/09, 04/03/09, 04/08/09, 04/15/09, 04/24/09, 04/28/09, 05/06/09, 05/08/09, and 05/12/09. This information was presented to the facility's director of nursing (DON - Employee #82) on 06/23/09 at 11:00 a.m., and she confirmed the physician should have signed and dated these outstanding orders. b) Resident #35 Medical record review, completed on 06/23/09, revealed the physician was in the facility and saw Resident #35 on 06/19/09. Further record review revealed telephone orders received prior to this visit which the physician did not sign, which had been given on 06/03/09, 06/08/09, 06/13/09, and 06/15/09. On the afternoon of 06/25/09, the DON, when interviewed, identified the physician recently came to her and told her he thought he was caught up with all documentation. The DON acknowledged at this time he must not be caught up with all the documentation. c) Resident #19 A review of the clinical record revealed verbal orders from the physician of Resident #19, given on 05/19/09, had not been signed by the physician as of 06/24/09, although he had visited the resident and had written a progress note on 06/05/09. During an interview with the administrator at 10:30 a.m. on 06/25/09, he acknowledged it appeared the physician had overlooked some of the orders. d) Resident #4 This resident had ten (10) telephone orders which had not been signed when the physician made his last visit on 06/22/09. These telephone orders were dated 05/23/09, 05/24/09, 05/27/09, 06/02/09, 06/03/09 (two (2) orders), 06/04/09, 06/07/09, 06/12/09, and 06/16/09. .",2014-09-01
11055,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,225,D,0,1,OJEL11,"Based on record review and staff interview, the facility failed to screen one (1) of nine (9) sampled employees (Employee #133) prior to hire, to ensure the individual had no findings that would indicate unfitness for service. Employee #133, a registered nurse (RN), indicated having licensure and prior work history in the State of Maryland. The facility failed to contact the Maryland RN licensing board to ensure Employee #133's RN license was not impaired. Facility census: 128. Findings include: a) Employee #133 A review of the personnel file of Employee #133 revealed she was hired as a RN on 04/06/09. Her written application indicated she was also licensed and had been employed in the State of Maryland. There was no evidence in her personnel file to indicate the facility verified the were no negative findings associated with Employee #133's RN licensed in Maryland. This was verified by the administrator at 10:45 a.m. on 06/25/09, who reported he was unaware of the need to verify the status of out-of-state professional licenses. .",2014-09-01
11056,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,247,D,0,1,OJEL11,"Based on record review and staff interview, the facility failed to notify the resident or the responsible party prior to transferring the resident to another room. This affected one (1) of twenty-eight (28) sampled residents. Resident identifier: #84. Facility census: 128. Findings include: a) Resident #84 A review of the clinical record revealed Resident #84 had been determined to lack capacity to understand and make health care decisions, although she was alert, able to communicate, and able to make her needs known, as documented in nursing notes on 06/19/09. Her son was serving as her health care surrogate. She was transferred from a room on 200 Wing to a room on 300 Wing. However, there was no documentation in the medical record to indicate that either she or her son was consulted prior to the room change. The nursing notes, at 10:45 a.m. on 06/18/09, recorded, when the son called to question the transfer, ""Informed was moved d/t (due/to) bed needs."" During an interview with the director of nursing (DON - Employee #82) at 9:30 a.m. on 06/25/09, she reviewed the record and expressed surprise that prior notice was not documented. .",2014-09-01
11057,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,285,B,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the mental health needs of applicants for admission were screened, in accordance with the Pre-Admission Screening and Resident Review (PASRR) program, prior to admission to the facility for three (3) of twenty-eight (28) sampled residents. Resident identifiers: #19, #74, and #113. Facility census: 128. Findings include: a) Resident #19 A review of the clinical record revealed Resident #19 was admitted to the facility on [DATE]. However, the PASRR determination with respect to a Level II evaluation was not made until after admission on 04/10/09, as indicated by the dated signature in Section V. During an interview with the social worker (Employee #128) at 11:00 a.m. on 06/24/09, he acknowledged this determination was made after the resident's admission to the facility. b) Resident #74 A review of the clinical record revealed Resident #74 was admitted to the facility on [DATE]. However, the PASRR determination with respect to a Level II evaluation was not made until after admission on 01/12/09, as indicated by the dated signature in Section V. During an interview with the social worker at 11:00 a.m. on 06/24/09, he acknowledged the determination was made after the resident's admission to the facility. c) Resident #113 The medical record of Resident #113, when reviewed on 06/23/09, disclosed the resident was admitted to the facility on [DATE]. Further review disclosed, at Item 42 on page 6 of the PASRR form, that a determination with respect to a Level II evaluation was not made until 03/25/09, after the resident's admission to the facility. .",2014-09-01
11058,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,315,D,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure one (1) of five (5) sampled residents with indwelling Foley urinary catheters had a valid physician's orders [REDACTED]. Resident identifier: #19. Facility census: 128. Findings include: a) Resident #19 A review of the medical record revealed Resident #19 was admitted to the facility from the hospital on [DATE], with an indwelling urinary catheter in place. The catheter was discontinued per physician's orders [REDACTED]. Resident #19 was readmitted to the facility on [DATE], with the catheter in place. There was no evidence of a physician's orders [REDACTED]. The resident was observed to have a urinary catheter in place at 2:00 p.m. on 06/22/09, while the resident's wife was being interviewed. This was confirmed by the director of nursing (DON - Employee #82) at 10:30 a.m. on 06/24/09, although she stated she had no explanation for the catheter's use in the absence of an order. .",2014-09-01
11059,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,441,D,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the effectiveness of the infection control program by allowing two (2) of nine (9) employees to care for residents without an annual screening for [DIAGNOSES REDACTED] (TB). This has the potential to effect all residents. Employee identifiers: #124 and #155. Facility census: 128. Findings include: a) Employee #124 A review of the employee health file for Employee #124, a licensed practical nurse, revealed her most recent TB screening was in 2006. b) Employee #155 A review of the employee health file for Employee #155, a licensed practical nurse, revealed her most recent TB screening was dated 01/06/08. c) During an interview with the administrator at 10:45 a.m. on 06/25/09, he explained the person in charge of employee health had recently resigned unexpectedly, and he acknowledged he could not find any evidence to show these employees had received their TB annual screening. .",2014-09-01
11060,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,492,D,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on medical record review and staff interview, the facility failed to provide information regarding Hospice to one (1) resident from a total sample of twenty-five (25), who recently received orders for ""comfort measures only"". This is required by W.V.C. 16-5C-20. Resident identifier: #4. Facility census: 128. Findings include: a) Resident #4 Medical record review, on 06/24/09, revealed this resident's Physician order [REDACTED]. Further review revealed no evidence the resident and family had been provided information regarding Hospice. Interview with the social worker, on the morning of 06/24/09, verified this information had not been provided as required. --- Part II -- Based on review of personnel files and staff interview, the facility failed to provide one (1) of three (3) certified nursing assistants, hired in 2009, with a copy of the Nurse Aide Abuse Registry legislative rule, as required by WV Legislative Rule 69-8.1. Employee identifier: #75. Facility census: 128. Findings include: a) Employee #75 A review of the personnel file of Employee #75, a nursing assistant who was hired on 06/08/09, failed to reveal any evidence that the facility had provided this employee with a copy of the Nurse Aide Abuse Registry legislative rule, as required by WV Legislative Rule 69-8.1. During an interview with the administrator at 10:45 a.m. on 06/25/09, he explained the person in charge of employee records had recently resigned unexpectedly, and he acknowledged he could not find any evidence to show this employee had received the required information. .",2014-09-01
11061,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,241,D,0,1,OJEL11,"Based on observation and staff interview, the facility's staff failed to provide care to residents in a manner that maintains and/or enhances each resident's self-esteem and self-worth, by failing to respond in a timely manner to a resident's request for assistance. Four (4) staff members were randomly observed to pass by (and not answer) an activated resident call light on the 100 Wing of the facility. Resident identifier: #29. Facility census: 128. Findings include: a) Resident #29 At 11:35 a.m. on 06/24/09, a staff member (Employee #116) was observed to pass by a resident-activated call light in a room on the 100 Wing of the facility. The employee was approached by this surveyor and, when asked if all staff was responsible for answering call lights, she stated, ""Yes."" It was pointed out to her that she had just passed by one without responding. She stated she had not noticed it, and she returned to the room occupied by Resident #29 and answered the light, turning it off. The call light was re-activated almost immediately, and at 11:40 a.m., three (3) additional staff members were observed to walk past the light, not responding. One (1) of the three (3) employees (Employee #161) was approached and asked who was responsible for answering call lights. Employee #161 responded, ""Everyone."" When informed that she and her co-workers had just failed to answer the light to Resident #29's room, Employee #161 stated that she had not noticed it was ringing. .",2014-09-01
11062,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,280,D,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed, for two (2) of twenty-five (25) residents sampled, to update the plan of care to reflect current needs. This included care received at an outside wound care clinic for one (1) resident and the use of a specialized air flow mattress for one (1) resident. Resident identifiers: #40 and #114. Facility census: 128. Findings include: a) Resident #40 The medical record of Resident #40, when reviewed on 06/23/09, disclosed the resident had acquired a Stage IV pressure ulcer during a hospitalization from which he was re-admitted to the facility on [DATE]. Shortly thereafter, the resident had begun weekly visits to and received treatments at an area wound care clinic. The resident's plan of care was reviewed. Although the plan did have interventions related to the resident's skin condition and care provided, the information was not correct at this time and did not mention the resident's weekly wound care clinic visits. This information was presented to the facility's director of nursing (DON - Employee #82) on 06/25/09, and no further information was available related to the a lack of revision to this resident's care plan. b) Resident #114 Observation, at 11:00 a.m. on 06/25/09, found this resident lying on a low air mattress with a raised border surrounding it. The mattress was a Stat 4000 Multizone Mattress which had a ""coverlay"" and required specific air flow settings. Review of the resident's care plan revealed the mattress was not currently identified on the care plan and had not been added to the care plan when its use was initiated on 05/20/09. .",2014-09-01
11063,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,281,D,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and review of the facility's ""Do Not Crush"" document, the facility failed to ensure one (1) of five (5) nurses administered medications in accordance with current professional standards of quality, by crushing and administering a medication that was noted to be in a form that should not be crushed. Resident identifier: #31. Facility census: 128. Findings include: a) Resident #31 A nurse (Employee #163) was observed performing medication administration at 8:35 a.m. on 06/24/09. This employee was noted to crush the medications she was preparing for Resident #31, which included [MEDICATION NAME], Vitamin D, [MEDICATION NAME], Sodium [MEDICATION NAME], and [MEDICATION NAME]. All of the medications were crushed with the exception of the [MEDICATION NAME], which Employee #163 stated the resident could swallow whole. Following the administration of the medication, the facility's ""Do not crush"" list available for nurse reference was requested and received from the facility's director of nursing (DON - Employee #82). Review of this document disclosed the medication [MEDICATION NAME] was a slow release medication and should not be crushed. The DON confirmed the findings when this information was provided at approximately 10:00 a.m. on 06/24/09. .",2014-09-01
11064,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,514,E,0,1,OJEL11,"Based on medical record review and staff interview, the facility staff failed to maintain resident medical records in accordance with accepted professional standards, by failing to ensure all documents in the record displayed a date of entry for two (2) of twenty-five (25) sampled residents. Resident identifiers: #15 and #113. Facility census: 128. Findings include: a) Residents #15 and #113 The medical records for Residents #15 and #113, when reviewed on 06/23/09, disclosed on both records documentation on a ""Progress Note"" form with a signature that appeared to be a large ""R"". The documents were also signed by the resident's attending physician. The information contained on the forms was a recapitulation of each resident's condition, including weight, medications, etc. The forms displayed no date to indicate when they were written and placed in the residents' records. The facility's director of nursing (DON - Employee #82), when questioned about these forms and documentation on 06/23/09 at 11:00 a.m., stated these forms were completed by the facility's restorative nurse. The DON confirmed the lack of a date to indicate when these entries were written.",2014-09-01
11065,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,364,F,0,1,OJEL11,"Based on observation, food temperature measurements, the confidential resident group interview, the facility's resident council meeting minutes, and staff interview, it was determined the facility failed to assure foods were attractive for residents on pureed diets, failed to assure hot foods were hot upon receipt by the resident, and failed to assure staff intervened when food were not hot enough. This practice had the potential to affect all facility residents who received nutrition from the dietary department. Facility census: 128. Findings include: a) Observation of the pureed foods, for the noon meal on 06/24/09, revealed all the foods were pale in color. When asked what the garnish was, the dietary manager (DM) stated the menu did not call for garnishes for pureed meals. After discussion, the pureed foods were garnished with parsley flakes, and a pureed apple slice was added to each plate. Dietary staff stated the food was much more attractive with the garnishes. b) Review of the past three (3) months of the facility's resident council meeting minutes revealed residents expressed concern regarding cold foods on 03/24/09. During the confidential group interview held with the residents at 1:45 p.m. on 06/23/09, five (5) of seven (7) responding residents stated that hot foods were not hot when they received them. During that meeting, residents also reported staff never offered to heat their meals for them. The residents said if they asked, staff would do this for them, but no offer was ever made. Observation revealed the meal service was begun at 11:40 a.m. on 06/24/09. The temperatures of the foods were not measured prior to beginning meal service. At 12:00 p.m., when more than half of the meals had not been served, food temperatures were measured. The pureed entree was 100 degrees Fahrenheit (F), pureed meat balls were 125 degrees F, potatoes were 130 degrees F, and mashed potatoes were 138 degrees F. Observations were made of tray delivery on the 100 hall, on 06/24/09. The cart arrived at 12:10 p.m. At 12:40 p.m., four (4) residents had not yet been served their meal. At 12:40 p.m., two (2) of these residents were served. The observation ended at 12:55 p.m., and the last two (2) residents had not yet been served their meal. .",2014-09-01
11066,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,363,E,0,1,OJEL11,"Based on menu review, observation, and staff interview, the facility failed to ensure menus were followed for residents ordered consistent carbohydrate (CC) and renal diets. This practice affected twelve (12) residents ordered CC diets, and had the potential to affect one resident who was ordered a renal diet. Facility census: 128. Findings include: a) Menu review revealed that residents on CC and renal diets were to receive cubed steak instead of a sausage / egg / cheese puff on 06/24/09. b) Observation of the service of the noon meal, on 06/25/09, revealed there was no cubed steak prepared. Residents on CC diets were served the sausage / egg / cheese puff. c) This was brought to the attention of the dietary manager (DM) during the meal service. At that time, she asked the cook if cubed steak had been prepared for these diets. The cook stated she did not notice that on the menu. At that time, the renal diet had not yet been served; therefore, the DM intervened, and the resident ordered a renal diet did not receive a sausage / egg / cheese puff. .",2014-09-01
11067,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,371,F,0,1,OJEL11,"Based on observation and staff interview, the facility failed to ensure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 128. Findings include: a) During the initial observation of the dietary department at 3:10 p.m. on 06/22/09, the following sanitation infractions were identified: 1. A staff member was using a container of filled with water to clean. When the water was tested , there was no sanitizing agent in the water. 2. A greasy substance was noted under the shelf at the food preparation sink. 3. Carrots from the previous meal were observed in the steam table water. 4. A large trash barrel had a large round hole cut in the lid. This practice caused the container to be an uncovered trash container in the kitchen. 5. One (1) male dietary employee did not have his mustache and beard covered to assure hairs did not fall into foods and/or onto food service items. Additionally, the female dietary personnel had loose hair outside of their hairnets. 6. Cakes were stored in the dry storage room. They were not covered to prevent possible contamination as staff went in and out of that room. 7. Steam table pans had not been fully air dried prior to stacking inside of each other, and these pans had crusty substances which could be scraped off with a fingernail, as well as a greasy debris on them. b) Observation revealed the meal service was begun at 11:40 a.m. on 06/24/09. The temperatures of the foods were not measured prior to beginning meal service. At 12:00 p.m., when more than half of the meals had not been served, food temperatures were measured. The pureed entree was 100 degrees Fahrenheit (F), pureed meat balls were 125 degrees F, potatoes were 130 degrees F, and mashed potatoes were 138 degrees F. To prevent the rapid growth of toxic microorganisms, which contribute to food borne illnesses, foods must be held for service at 135 degrees F or above. .",2014-09-01
11068,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,323,E,0,1,OJEL11,"Based on observation, staff interview, and medical record review, the facility failed to assure one (1) of one (1) resident's side rail padding was applied correctly, and failed to assure an electrical cover was properly secured flush to the floor so as not to present a trip hazard. These practices had the potential to result in injury to the resident with the side rails, and in injury to any resident who was ambulating near the kitchen entrance. Resident identifier: #4. Facility census: 128. Findings include: a) Resident #4 During the initial tour at 2:30 p.m. on 06/22/09, this resident was observed lying in bed with a device between each of the side rails and the resident. The devices had slid down and were not fully covering the side rails. On 06/24/09 at 10:00 a.m., this resident was observed with a nursing assistant (NA) present. Upon inquiry, the NA stated the devices were to protect the resident, because he often leaned his face into the side rails. At that time, the NA noted the devices had slid down, exposing the side rails. The NA then repositioned the devices. During the afternoon of 06/25/09, the resident was again observed with the director of nursing (DON - Employee #82) present. When shown the devices, which again had slid off the side rails, the DON stated the devices were not properly applied. At that time, the DON demonstrated how the devices were supposed to be applied. They were supposed to be affixed with Velcro, which was a part of each device. When applied correctly, the safety devices remained in place and protected the resident from the side rails. b) Observation, on 06/23/09 at 10:00 a.m. and 06/24/09 during the early afternoon, revealed a metal electrical cover attached to the floor, in the hallway near the kitchen. This cover was not flush with the floor and created a trip hazard. Residents were observed ambulating in this area throughout each day of the survey. .",2014-09-01
11131,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-28,242,D,1,0,UJUP11,". Based on medical record review, observation, and staff interview, the facility failed to honor a resident's right to receive a Kosher diet, in recognition of her lifelong religious beliefs and practices, and failed to communicate the specifics of how a Kosher diet was to be prepared to the dietary kitchen staff. This was true for one (1) of thirty-two (32) Stage II sample residents. Resident identifier: #48. Facility census: 124. Findings include: a) Resident #48 Review of the resident's care plan, created on 11/22/10, revealed the following problem statement: ""Resident is at nutritional risk due to receiving a mechanically altered diet. Due to Jewish religious beliefs, resident eats Kosher and has several food preferences. She had a significant wt. (weight) loss x (symbol for times) 30 days."" Approaches to this problem included: ""Honor food preferences within meal plan and maintain resident's cultural food preferences as obtained by FSD (food service director)."" Observation, on 04/27/11 at approximately 12:10 p.m., revealed Resident #48 was served a pork tenderloin while in the North dining room. Employee #101 (a nursing assistant) delivered a tray to the resident at her table. When Employee #101 removed the covering from the resident's plate, he returned the tray to a dietary employee and stated the resident was not to be served pork. The dietary staff then prepared another tray for the resident. -- On 04/27/11 at approximately 1:45 p.m., the food service director (FSD - Employee #133) and the food service assistant (Employee #180) were asked how they would prepare a Kosher diet. Employee #133 stated a Kosher diet means ""no pork, no pork products, and meat and cheese cannot be on the same plate together."" Employee #180 stated, ""Meat and dairy cannot be touching on the same plate."" Employee #180 also stated if the facility was to serve a ""real Kosher diet"", the kitchen would have to purchase separate pots and pans just to cook the resident's food. He explained that if pork was cooked in a pan, the resident would not be able to eat anything else cooked in this pan. Employee #180 stated he had spoken with the resident's family and the family stated the facility could serve a ""mellow Kosher diet"". When asked how they conveyed this information to the dietary employees, Employee #133 stated the specifications were on the resident's tray card. The tray card for Resident #48, when observed, documented the resident had dislikes of pork and bacon and was to receive 4 ounces of milk. Employee #180 verified the facility's care plan approach to ""maintain resident's cultural food preferences as obtained by the FSS"" was not sufficiently detailed on the tray card for dietary staff to know how to prepare and serve this resident's food. .",2014-08-01
11132,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-14,225,E,1,0,VVWG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on record review, policy review, and staff interview, the facility failed to substantiate as neglect the lack of care for five (5) of ten (10) sampled residents (#1, #36, #39, #54, and #75), as defined in the facility's abuse prohibition policy. After shift change at approximately 3:30 p.m. on 04/04/11, the oncoming CNA (Employee #10) reported to the licensed practical nurse (LPN - Employee #77) having found these five (5) residents ""soaked"" with urine, with Resident #75 complaining of being wet and burning, and Resident #39 having been found ""lying in a bed of urine, still wet with dry yellow rings around the edges of the draw sheet"". The facility's internal investigation identified Employee #111 as the CNA having been assigned to care for these residents on the 7:00 a.m. to 3:00 p.m. (7-3) shift on 04/04/11. Review of the facility's five-day follow-up reports and interview with the administrator (Employee #69) and the manager of clinical operations (Employee #156), on the afternoon of 04/13/11, found the facility did not determine that Employee #111 had neglected the above residents. Resident identifiers: #1, #36, #39, #54, and #75. Facility census: 124. Findings include: a) Residents #1, #36, #39, #54, and #75 Review of the facility's internal investigations into allegations of abuse / neglect found documentation stating that, when Employee #10 came on duty for the 3-11 shift on 04/04/11 and began his first rounds at 3:05 p.m., he found five (5) of the twelve (12) residents who had been assigned to Employee #111 (the 7-3 shift CNA) were saturated with urine. - In a statement written by Employee #10 on 04/04/11, he stated (quoted as written): ""On 4-4-11 at 3:05 pm I (name of Employee #10) was getting report from CNA (name of Employee #111). She stated to me that she had just got finished doing her first round a couple of minutes ago and that everyone was dry and clean. That's when (name of Resident #75) in (room number) on south unit, stated she was wet an burning. Proceeded to check resident and she was soaking wet. ""CNA (name of Employee #111) was still present at that time. I told (Employee #111) that she could go head and leave and that I would go head an change her, because I thought (Resident #75) was just wet from consuming a lot of fluids early in the day. But as I proceeded to continue my round It became a pattern. (Name of Resident #1) resident in (room number) was soaked with urine in her brief, after changing her proceeded to (room number) (name of Resident #36) where I found him soaked even though he has a foley (indwelling urinary catheter), it leaks. Proceeded to (room number) beds A & B resident, both resident (#54 and #39) soaked with exceptions of (name of Resident #39) was a total bed. Meaning she was lying in a bed of urine still wet with dry yellow rings around edge of draw sheet indicating she's been lying in it for awhile. That's when I reported & showed nurse (Employee #77), because that was just to many residents soaked like that at one time."" - In a statement written by Employee #77 on 04/04/11, she stated (quoted as written): ""On 4/4/11 at approximately 3:30 p.m. 3-11 CNS made this nurse aware that resident in (room number) bed B (Resident #39) was wet, stated 'I need you to come look at something' checked residents draw sheet and brief. Noted to be wet, draw sheet dry /c (with) brown / yellow ring noted."" - 1. Resident # 75 According to Section G of a minimum data set (MDS) assessment dated [DATE], this [AGE] year old female was totally dependent on the assistance of one (1) person for toilet use and personal hygiene. 2. Resident #1 According to Section G of an MDS dated [DATE], this [AGE] year old female was totally dependent on the assistance of one (1) person for toilet use and personal hygiene. 3. Resident #36 According to Section G of an MDS dated [DATE], this [AGE] year old male was totally dependent on the assistance of one (1) person for toilet use and personal hygiene. 4. Resident #39 According to Section G of an MDS dated [DATE], this [AGE] year old female was totally dependent on the assistance of one (1) person for toilet use and personal hygiene. 5. Resident #54 According to Section G of an MDS dated [DATE], this [AGE] year old female was totally dependent on the assistance of one (1) person for toilet use and personal hygiene. -- b) Review of the facility's internal investigations into allegations of neglect involving each of the above residents found the same result (quoted as written): ""After investigation it was determined that the allegation of neglect was unsubstantiated. CNA (name of Employee #111) was re-educated on changing residents that are incontinent and rounding closer to end of shift."" -- c) Review of the facility's policy titled ""1.0-WV Abuse Prohibition"" (effective 06/01/96 and revised 11/01/09) found the following definition: ""Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."" -- d) In an interview on the afternoon of 04/13/11, the administrator and the manager of clinical operations reported the facility did not determine that Employee #111 had neglected the above residents. --- Part II -- Based on record review and staff interview, the facility failed to immediately report two (2) of two (2) injuries of unknown source discovered when reviewing the facility's incident / accident reports from March 2011. Resident #22 was discovered to have purple bruises on the right and left buttocks on 03/28/11. Resident #84 had abrasions on the tops of both feet. The causes of these injuries were not witnessed, the residents could not relate to staff how they occurred, and the injuries were suspicious in nature due to their locations. Interview with the administrator, on 04/13/11 at 2:00 p.m., confirmed no immediate or follow-up reporting of these injuries was made to State agencies as required. Resident identifiers: #84 and #22. Facility census: 124. Findings include: a) Resident #84 Review, on 04/12/11, of facility incident / accident reports for the month of March 2011 found an incident report was initiated for Resident #84 on 03/15/11 at 3:00 p.m., for ""unwitnessed"" abrasions on the tops of both feet. The description of the incident stated (quoted as written), ""Abrasions noted to top of Right & Left feet. Previously noted to right foot on 3/3/11. Noted to left foot on 3/13/11."" The abrasion on the right foot measured 5 cm x 0.4 cm (with no depth), and the abrasion on the top of the left foot measured 9 cm x 0.5 cm (also with no depth). First aid was to include: ""RN assessment - cleanse abrasions, pat dry, apply SurePrep."" This report indicated the event(s) causing the abrasions were unwitnessed, and no known cause documented on the form. - Review of the facility self-reported events for March 2011 found these injuries were not immediately reported to State agencies (within no greater than twenty-four (24) hours of their discovery). - In an interview with the administrator and the manager of clinical operations on 04/13/11 at 1:45 p.m., they stated the injuries were not reported, because the facility knew what caused them. In a follow-up interview at 2:00 p.m. on 04/13/11, the administrator presented an incident / accident investigation form that had been completed by the facility on 03/18/11. - Review of the facility's investigation into this incident found under the heading ""Possible Causes for Incident"": ""Abrasions to bilateral top of feet may have been caused by socks or resident's position. Resident very restless @ (at) times."" - The facility investigated the injuries but failed to immediately report them to State agencies, and failed to provide follow-up reporting of the results of the internal investigation to State agencies as required. -- b) Resident #22 Review, on 04/12/11, of facility incident / accident reports for the month of March 2011 found an incident report involving Resident #22 dated 03/28/11, noting staff discovered bruises on the resident's right and left buttocks. The description of the incident stated (quoted as written), ""CNA notified this nurse of bruise on (L) & (R) buttock."" The description of the injury stated (quoted as written), ""Purple linear bruise (L) buttock 4 cm x 0.4 cm. Round purple bruise 0.3 x 0.3 cm."" This report indicated event causing the bruises was unwitnessed, and no known cause documented on the form. - Review of the facility self-reported events for March 2011 found these injuries were not immediately reported to State agencies (within no greater than twenty-four (24) hours of their discovery). - In an interview with the administrator and the manager of clinical operations on 04/13/11 at 1:45 p.m., they stated the injuries were not reported, because the facility knew what caused them. - In a follow-up interview at 2:00 p.m. on 04/13/11, the administrator presented an incident / accident investigation form that had been completed by the facility on 03/29/11. - Review of the facility's investigation into this incident found under the heading ""Possible Causes for Incident"": ""Bruises noted to be at area of where open shower chair lid is."" - The facility investigated the bruises but failed to immediately report them to State agencies, and failed to provide follow-up reporting of the results of the internal investigation to State agencies as required. .",2014-08-01
11133,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2011-04-14,309,G,1,0,VVWG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, and staff interview, the facility failed to provide care and services for one (1) of ten (10) sampled residents to prevent an avoidable decline in the condition of a left foot abrasion. On 03/15/11, documentation in Resident #84's medical record described the presence of an ""intact"" abrasion across the top of the resident's left foot. On 03/16/11, a TED (compression) hose was applied to his foot to reduce [MEDICAL CONDITION]. A clarification order, also dated 03/16/11, directed nursing staff to: ""Check skin integrity below TED hose Q (every) shift."" On 03/27/11, facility documentation noted the wound had decreased in length, increased in width, and was described as being ""intact"" with a ""scab"" present. On 03/30/11, Resident #84 was sent to the hospital at the request of his family for evaluation of the wound. Hospital records revealed this resident had a Stage III pressure sore with damage down to the fascia and required antibiotic therapy for [MEDICAL CONDITION] (infection into the tissues). Medical record review disclosed skin assessments (which were to be done on every shift after the application of the compression hose) were not completed in accordance with a physician's orders [REDACTED].#84. Facility census: 124. Findings include: a) Resident #84 1. Medical record review, on 04/13/11, revealed this [AGE] year old male resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. This resident was alert and answered simple questions appropriately but had some cognitive and perceptual deficits. His physician determined he lacked the capacity to understand and make informed medical decisions for himself, and his medical power of attorney (MPOA) was serving as his surrogate decision-maker. According to the resident's current comprehensive care plan, which was provided by the facility's staff development nurse (Employee #5) on 04/14/11, this resident was non-ambulatory and dependent upon staff for all activities of daily living (ADLs). -- 2. Review, on 04/12/11, of facility incident / accident reports for the month of March 2011 found an incident report was initiated for Resident #84 on 03/15/11 at 3:00 p.m., for ""unwitnessed"" abrasions on the tops of both feet. The description of the incident stated (quoted as written), ""Abrasions noted to top of Right & Left feet. Previously noted to right foot on 3/3/11. Noted to left foot on 3/13/11."" The abrasion on the right foot measured 5 cm x 0.4 cm (with no depth), and the abrasion on the top of the left foot measured 9 cm x 0.5 cm (also with no depth). First aid was to include: ""RN assessment - cleanse abrasions, pat dry, apply SurePrep."" Review of the facility's investigation into this incident (completed on 03/18/11) found under the heading ""Possible Causes for Incident"": ""Abrasions to bilateral top of feet may have been caused by socks or resident's position. Resident very restless @ (at) times."" -- 3. Review of nursing notes, dated 03/13/11 (prior to completion of the incident report) documented (quoted as typed): ""(Resident #84) has a new onset / change in skin integrity as evidenced by abrasion. Location: top of left foot. ... New orders obtained. Cleanse site with w/c, pat dry, apply non sting sureprep to site Qshift and leave open to air."" A nursing note, dated 03/15/11 at 12:28 p.m., stated: ""Lotion applied to bilateral feet per this nurse at this time. Feet dry. Left foot swollen. MPOA aware. Will address with MD."" A nursing note, dated 03/15/11 at 15:33 (3:33 p.m.), stated (quoted as typed): ""... New orders noted for ted hose, wound nurse consult D/T (due to) previously noted areas on top of feet, and A & D ointment to bilateral feet. MPOA aware of new orders."" A nursing note, dated 03/16/11 at 17:24 (5:24 p.m.), stated (quoted as typed): ""Order clarification for ted hose to be worn to left leg at all times. Check skin integrity Q shift below ted hose. ..."" -- 4. Review of his physician's orders [REDACTED]. Wound care nurse eval."" A notation on the order stated (quoted as written), ""done 3/15/11 3:45 p.m."" Another order was written later on 03/15/11 for: ""(1) A&D ointment to bilateral feet Q (every) shift D/T (due to) dry skin. (2) No sting sureprep to to (sic) top of left foot Q day D/T abrasion."" Further review found the following clarification order dated 03/16/11: ""TED hose to left leg at all times. Check skin integrity below TED hose Q shift."" On 03/30/11, an order was received to: ""Place TED hose on hold until abrasion to top of left foot is resolved."" Also on 03/30/11, an order was received to: ""Send resident to (local hospital) ER (emergency room ) for evaluation abrasion & swelling to left foot."" -- 5. An assessment recorded by nursing staff at the ER at 19:56 (7:56 p.m.) on 03/30/11 stated (quoted as typed): ""... Skin not intact. Pressure sore with damage down to fascia (Stage III) noted. Located on left ankle. Present on arrival (area on lateral ankle and at flexion point of joint). ..."" (Note: The definition of a Stage III pressure sore is: ""Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue."") Further review of the hospital records disclosed Resident #84 was treated in the ER with intravenous (IV) antibiotics ([MEDICATION NAME] and [MEDICATION NAME]), and he was discharged back to the facility with an order for [REDACTED]. According to the nursing notes, Resident #84 returned to the facility at 3:30 a.m. on 03/31/11. The physician's assistant saw Resident #84 on the afternoon of 03/31/11 and gave the following orders at 3:45 p.m.: ""1) D/C (discontinue) order for Sureprep to top of Lt (left) foot. 2) Cleanse top of Lt foot /c (with) wound cleanser, Pat dry. Apply [MEDICATION NAME] gel & cover /c dry dressing. Change daily & PRN. 3) Consult wound clinic. 4) Keflex 500 mg po (by mouth) qid (four (4) times a day) x 10 days for [MEDICAL CONDITION]."" -- 6. On 04/13/11, the facility's nurse practice educator (NPE), a registered nurse (RN - Employee #5) was asked for evidence of the weekly skin assessments and the skin integrity assessments (ordered on [DATE]) to be done on every shift following the application of the TED hose to Resident #84. Employee # 5 stated these assessments would have been recorded in the nursing notes on every shift. -- 7. Review of nursing notes from 03/16/11 (when the TED hose to the left foot was ordered) to 03/30/11 (when application of the TED hose was put ""on hold"") found no evidence of skin assessments of the left foot having been completed on every shift as ordered. - A nursing note, dated 03/17/11 at 9:27 a.m., stated: ""Previously noted abrasions to top of right foot and top of left foot continue. Skin continues to be very dry to bilateral feet. A & D ointment continues D/T dry skin. Applied per this nurse."" - A nursing note, dated 03/20/11 at 15:08 (3:08 p.m.), stated: ""... TED hose to left leg in place. ..."" There was no indication the skin integrity had been checked. - A nursing note, dated 03/22/11 at 00:38 (12:38 a.m.), stated: ""... TED hose to LLE (left lower extremity) in place ..."" There was no indication the skin integrity had been checked. - A nursing note, dated 03/22/11 at 12:16 p.m., stated: ""... TED hose in place to LLE. ..."" There was no indication the skin integrity had been checked. No further nursing notes were made regarding the TED hose until 03/27/11 at 18:49 (6:49 p.m.), when the nurse recorded (quoted as typed): ""... Resident medicated x 3 this shift, resident crying out in pain this evening during dinner crying out and stating to please put him in bed, could not tolerate the pain. Some pain relief noted after assisting resident back to bed. Resident continues with 25mcg [MEDICATION NAME] and [MEDICATION NAME] 10 Q4 prn (every 4 hours as needed) for pain. Ted hose removed from left leg and kept off due to abrasion to ankle with indentation from ted hose. ..."" - A nursing note, dated 03/29/11 at 13:48 (1:48 p.m.), stated: ""... MD PA (physician's assistant) in to see resident. ..."" -- 8. Review of a progress note related to physician service visit on 03/29/11 found the following under the heading ""Chief complaint / History of present illness"": ""... (L) ankle still has ulcer."" Under the heading ""Assessment / Plan"" was written: ""... (5) Abrasion / ulceration ..."" No description of this ulceration was recorded. A previous entry related to a physician service visit on 03/23/11 made no mention of the presence of this wound. An entry related to a physician service visit on 03/15/11 stated: ""... mild abrasion improving ..."" -- 9. Further review of nursing notes revealed a late entry by the wound nurse (Employee #72), entered at 15:30 (3:30 p.m.) on 03/29/11, stating: ""Went to room to evaluate abrasion to top of L (left) foot. Abrasion measurements obtained and noted to be increased. Scab intact. ..."" - A nursing note, on 03/30/11 at 17:20 (5:20 p.m.), revealed the resident's sister / MPOA had become concerned about the condition of the resident's left foot and stated she would like the resident to be sent to the hospital ER (emergency room ) to be evaluated by a ""real doctor"" for the abrasion and swelling of the left foot. - A nursing note, dated 03/30/11 at 18:50 (6:50 p.m.), stated the resident was transported to the hospital ER. (The resident returned to the facility at 3:30 a.m. the next morning.) -- 10. Review of the resident's Skin Integrity Report, completed by the wound nurse weekly, revealed the wound nurse began weekly observations and measurements of the abrasion to the top of Resident #84's left foot on 03/15/11. - When it was discovered on 03/15/11, documentation on the Skin Integrity Report described the abrasion as 9 cm in length and 0.5 cm in width with no depth, and the surrounding tissue and wound edges were described as healthy. - On 03/21/11, documentation on the Skin Integrity Report indicated the skin was intact, length was 9 cm, width was 0.5 cm, the surrounding tissue was healthy, and no drainage was present. - On 03/27/11, documentation on the Skin Integrity Report indicated the skin was intact with a scab. The length was 5 cm, the width was 1.3 cm, the surrounding tissue was red, and the wound edges were healthy. - On 03/29/11, documentation on the Skin Integrity Report indicated the skin was intact with a scab, the length was 2.1 cm and width was 5.1 cm. The surrounding tissues and wound edges were described as healthy with no drainage present. -- 11. According to the weekly Skin Integrity Report, between 03/21/11 and 03/27/11, the wound on top of the resident's left foot decreased in length (from 5 cm to 2.1 cm), increased in width (from 1.3 cm to 5.0 cm), and declined from being intact to being intact with a scab present. There were no nursing notes, physician progress notes [REDACTED].#84's medical record describing any changes that had occurred to the wound on his left foot between these two (2) Skin Integrity Reports. A progress note recording physician service visit on 03/29/11 noted ""(L) ankle still has ulcer"" and ""abrasion / ulceration"", although the terms ""ulcer"" and ""ulceration"" were not used by nursing staff in the facility when describing this wound - which was referred to only as an ""abrasion"" that was intact. An assessment of the resident's foot, completed by nursing staff in the hospital'sER on [DATE], described the skin on the resident's left foot as ""not intact"" and as being a Stage III pressure sore involving the fascia. This failure to monitor the skin integrity of the resident's left foot after applying the TED hose, which already had an abrasion across the top, resulted in delayed identification and treatment of [REDACTED].",2014-08-01
11376,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2010-12-09,157,D,,,3ZOF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the electronic medical record, staff interview, family interview, and incident report review, the facility failed to immediately inform the legal representative when one (1) of nine (9) sampled residents was involved in an incident requiring physician intervention. Resident #100, who had a history of [REDACTED]. After the son intervened, staff contacted the physician and Resident #100 was subsequently sent to the hospital where she was diagnosed with [REDACTED]. Facility census: 115. Findings include: a) Resident #100 On 11/16/10 at approximately 9:00 a.m., a family interview revealed Resident #100's son, who was also her legal representative, did not receive notification that his mother fell on [DATE] until he came to the facility on [DATE] and found a bruise on her shoulder. - Documentation on an incident report dated 10/16/10, when reviewed on 11/16/10 at approximately 1:00 p.m., revealed the nurse wrote, ""As I was starting up the hallway, to do my med pass heard resident in (room #) yelling out. When entered the room and walked to her side (sic) she already started out of the bed on her arms before I got to her; the bottom half slithered out. Asked resident if she could get up and she attempted but went down on her right side."" Documentation on the report related to notification of the resident's responsible party found the son was not notified of the fall until 5:00 p.m. on 10/17/10. - Review of Resident #100's electronic medical record, on 11/16/10 at approximately 2:00 p.m., revealed a nursing progress note identified as a ""late entry"" and dated 10/16/10 at 21:00 (9:00 p.m.) which stated, ""As I was walking up the hallway to do my med pass. Writer heard resident yelling out. When entered the room and walked to her side. She already started out of the bed on her arms before I could get to her; the bottom half slithered out and onto the mat. Asked resident if she could get up and she attempted but went down onto her right side. I then went out and got CNA's (certified nursing assistants) to help assist resident back into bed. When I had given the resident her meds which I had already had in the room with me at that time (sic). I assessed and did not see any injuries at this time. Resident did not complain of any pain nor distress noted."" A nursing progress note dated 10/17/10 at 18:20 (6:20 p.m.) stated, ""At 5pm (sic) son reported to this nurse that he found a bruise on resident's shoulder. This nurse noted bruise to right shoulder dark purple in color. Tylenol administered as ordered prior to family arriving. Family requested to speak with administrator and called his cell phone. Paged Dr. (name) and obtained stat order for xray to right shoulder. Called quality (sic) Mobile with new order. Administrator and DON (director of nursing) came in and talked with the family. Family then requested that resident be sent to ER for xray. B/P 123/69 Temp 98.6 R18 P87 O2 sats 95%. Called Life Ambulance but had no ambulance available. Called 911 for transport to ER. Resident left facility at 6:20 pm."" - A nursing progress note dated 10/17/10 at 23:46 (11:46 p.m.) stated: ""Resident returned to facility at this time, via ambulance stretcher alone, family did not accompany her at this time, received report from d/c nurse at (name of hospital), she stated she has a FX (fracture) to her right clavicle and will be returning with an immobilizer to right arm...."" - On 11/17/10 at approximately 1:00 p.m., the administrator and director of nursing agreed the facility should have contacted the resident's son on 10/16/10 after the fall occurred. .",2014-04-01
11377,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2010-12-09,441,F,,,3ZOF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's policies and procedures, staff interview, and review of information published on the Internet by the Mayo Clinic and the American Academy of Family Physicians on the topic of scabies, the facility failed to fully implement appropriate measures to control the spread of scabies and to prevent possible re-exposure and re-infestation, in accordance with the facility's infection control policies and procedures and accepted standards of professional practice. These practices had the potential to result in more than minimal harm to all residents. This is a REPEAT DEFICIENCY, as the facility was cited for non-compliance with this requirement related to the handling of an outbreak of scabies during a complaint investigation completed on 06/16/10. Resident identifiers: #36, #98, #13, and #40. Facility census: 115. Findings include: a) Observations, during a tour of the facility beginning on 11/15/10 at 7:15 p.m., found several open clear plastic bags in residents ' rooms throughout the facility. In an interview on 11/15/10 at 7:15 p.m., a nursing assistant (Employee #145) confirmed the facility had an outbreak of scabies. Employee #145 stated, ""We are to leave all the residents' personal items that cannot be washed in a sealed plastic bag for 7 days. November 19th will be the last day."" The bags, when examined, were not labeled to instruct staff, residents, and/or visitors to not open them until a certain date had come to pass, nor was there any way to determine whether the items in the bags had remained contained for a period of at least seven (7) days. The nursing assistants, when questioned about these bags, confirmed they had to remain sealed until seven (7) days after they were originally bagged. - According to the facility's policy titled ""4.12 Scabies"" (last revised on 02/01/10), the following process was to be implemented: ""5 - Implement procedures to eliminate infestation and prevent transmission to others. ""5.1 - Use Contact Precautions until 24 hours after treatment is administered. ... ""5.2 - Simultaneously treat all persons affected. All symptomatic health care workers, visitors, volunteers, and their contacts should be treated. Asymptomatic family members, roommate, and anyone who has had skin to skin contact with the patient should also be treated. ""5.2.1. - Develop a contact list to identify all persons who had direct physical contact with the patient and their contacts. ... ""5.4 - Place unwashable items (shoes, slippers, pillows, stuffed animals, etc.) in a plastic bag and keep sealed for seven days. ""5.4.1 - Label bag 'Do Not Open until ____ (date).'"" - An Internet search of the Mayo Clinic website on the topic of scabies revealed the following: ""To prevent re-infestation and to prevent the mites from spreading to other people, take these steps: ""Clean all clothes and linen. Use hot, soapy water to wash all clothing, towels and bedding you used at least three days before treatment. Dry with high heat. Dry-clean items you can't wash at home. ""Starve the mites. Consider placing items you can't wash in a sealed plastic bag and leaving it in an out-of-the-way place, such as in your garage, for a couple of weeks. Mites die if they don't eat for a week..."" (Source: http://www.mayoclinic.com/health/scabies/DS ) - Subsequent observations during tour of the facility with the administrator (Employee #68) on 11/15/10 found the following: - At 7:45 p.m., Resident #36 was rummaging through a clear plastic bag on the floor of her room. There was no label attached to the bag to identify that the bag should not be opened until a specific date. Resident #36 had over ten (10) clear plastic bags full of unwashable items in the corner of her room with no labels. - At 7:55 p.m., Resident #13's room was noted to have a clear plastic bag that was too full and could not be sealed. The bag was not labeled to identify when it was safe to open. - A follow-up tour with the administrator on 11/16/10 revealed the following: - At 10:00 a.m., Resident #98 had a clear plastic bag in her room containing stuffed animals and flower arrangements. The bag had no label identifying when it was safe to open. The administrator stated, ""I swear everything was labeled."" At 10:15 a.m., Resident #40 had a clear plastic bag full of personal items stuffed under her bed. The bag was torn, and loose items were out on the floor. The bag, which was also not labeled, was identified to the administrator. - The action item of bagging all unwashable personal items for a period of seven (7) days was not fully implemented as required by facility policy. -- b) Interview with the director of nursing (DON), on 11/17/10 at 10:15 a.m., revealed the facility recently had an outbreak of scabies among both staff and residents. When asked how many individuals were affected, she reported one (1) resident and one (1) employee were actually diagnosed with [REDACTED]. Review of the infection control monthly line listing revealed three (3) residents who were identified with a rash. Review of facility documentation revealed the administrator, on 11/5/10 at 1:30 p.m., notified the county health department of a confirmed case of scabies. (Resident #103 was sent to a dermatologist on 11/01/10, where he was biopsied, and he was confirmed to have scabies at 11:27 a.m. on 11/04/10.) At first, the facility treated only seventeen (17) residents on one (1) unit. On 11/09/10 at approximately 10:45 a.m., the facility again contacted the local health department (LHD) to report they identified another resident with a rash on another unit. According to facility's ""Scabies Case / Contact Line-Listing Form: Patients: "" submitted to the LHD on 11/09/10, the facility reported having five (5) residents with a rash (#103, #92, #86, #5, and #116); these cases were identified between 11/01/10 and 11/08/10. According to the facility's ""Scabies Cleaning Timeline - 11/5/10"", the following timeline of actions was to be implemented: 11/05/10: - Contact families for 100 hall - Bag all clothes and wash clothes for 100 Hall - Bag all non-washable items for seven (7) days for 100 Hall - Cream ([MEDICATION NAME]) patients on 100 hall 11/06/10: - Shower the 100 Hall residents - Clean 100 hall rooms 11/09/10: - Contact the remaining of North families - Bag all clothes and wash clothes for North - Bag all non-washable items for 7 days for North - Cream patients on North 11/10/10: - Shower the remaining of North Residents - Clean the remaining of the North rooms - Contact Families on TCU - Bag all clothes and wash clothes for TCU - Cream patients on TCU - Vacuum Floors 11/11/10: - Give the Med Ivermectin for TCU and North - Clean the TCU rooms - Rewash 100 Hall clothes - Contact Families on South - Bag all clothes and wash clothes for South - Bag all non-washable items for 7 days for South - Vacuum floors 11/12/10: - Give the Med Ivermectin for South residents - Clean the South rooms - Clean all Dining Room Chairs and Dining Rooms - Vacuum Floors - The action item of simultaneously treating all persons affected (including all symptomatic and asymptomatic health care workers, visitors, volunteers, family members, roommate, and anyone who had skin-to-skin contact with the resident) when the first case of scabies was confirmed was not implemented as required by facility policy. -- c) During an interview on 11/16/10 at 11:35 a.m., the administrator stated all residents and staff were administered Ivermectin by mouth on 11/12/10, with the exception of three (3) employees. One (1) was pregnant and chose to see her physician instead; the other two (2) employees received the topical cream [MEDICATION NAME]. - An Internet search regarding the use of oral Ivermectin to treat scabies infections revealed the following article published in the American Family Physician (the peer reviewed journal for the American Academy of Family Physicians): ""Oral ivermectin is an effective and cost-comparable alternative to topical agents in the treatment of [REDACTED]. Oral dosing may be more convenient in institutional outbreaks and in the treatment of [REDACTED].S. Food and Drug Administration has not approved the drug for the treatment of [REDACTED]."" (Source: http://www.aafp.org/afp/2003/0915/p1089.html Am Fam Physician. 2003 Sep 15;68(6):1089-1092.) .",2014-04-01
11378,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2010-12-09,490,F,,,3ZOF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's policies and procedures, staff interview, and review of information published on the Internet by the Mayo Clinic and the American Academy of Family Physicians on the topic of scabies, the governing body failed to ensure the facility was administered in an efficient and effective manner to maintain the highest practicable physical well-being of all residents and others. The facility's administration failed to oversee and ensure the infection control policies and procedures were implemented as written to manage an outbreak of scabies and prevent transmission to others inside and outside the facility. This practice has the potential to cause more than minimal harm to all residents, staff, and visitors. This is a REPEAT DEFICIENCY, as the facility was cited for non-compliance with this requirement related to the governing body's failure to ensure the facility responded appropriately to an outbreak of scabies during a complaint investigation completed on 06/16/10. Resident identifiers: #36, #98, #13, and #40. Facility census: 115. Findings include: a) Observations, during a tour of the facility beginning on 11/15/10 at 7:15 p.m., found several open clear plastic bags in residents ' rooms throughout the facility. In an interview on 11/15/10 at 7:15 p.m., a nursing assistant (Employee #145) confirmed the facility had an outbreak of scabies. Employee #145 stated, ""We are to leave all the residents' personal items that cannot be washed in a sealed plastic bag for 7 days. November 19th will be the last day."" The bags, when examined, were not labeled to instruct staff, residents, and/or visitors to not open them until a certain date had come to pass, nor was there any way to determine whether the items in the bags had remained contained for a period of at least seven (7) days. The nursing assistants, when questioned about these bags, confirmed they had to remain sealed until seven (7) days after they were originally bagged. - According to the facility's policy titled ""4.12 Scabies"" (last revised on 02/01/10), the following process was to be implemented: ""5 - Implement procedures to eliminate infestation and prevent transmission to others. ""5.1 - Use Contact Precautions until 24 hours after treatment is administered. ... ""5.2 - Simultaneously treat all persons affected. All symptomatic health care workers, visitors, volunteers, and their contacts should be treated. Asymptomatic family members, roommate, and anyone who has had skin to skin contact with the patient should also be treated. ""5.2.1. - Develop a contact list to identify all persons who had direct physical contact with the patient and their contacts. ... ""5.4 - Place unwashable items (shoes, slippers, pillows, stuffed animals, etc.) in a plastic bag and keep sealed for seven days. ""5.4.1 - Label bag 'Do Not Open until ____ (date).'"" - An Internet search of the Mayo Clinic website on the topic of scabies revealed the following: ""To prevent re-infestation and to prevent the mites from spreading to other people, take these steps: ""Clean all clothes and linen. Use hot, soapy water to wash all clothing, towels and bedding you used at least three days before treatment. Dry with high heat. Dry-clean items you can't wash at home. ""Starve the mites. Consider placing items you can't wash in a sealed plastic bag and leaving it in an out-of-the-way place, such as in your garage, for a couple of weeks. Mites die if they don't eat for a week..."" (Source: http://www.mayoclinic.com/health/scabies/DS ) - Subsequent observations during tour of the facility with the administrator (Employee #68) on 11/15/10 found the following: - At 7:45 p.m., Resident #36 was rummaging through a clear plastic bag on the floor of her room. There was no label attached to the bag to identify that the bag should not be opened until a specific date. Resident #36 had over ten (10) clear plastic bags full of unwashable items in the corner of her room with no labels. - At 7:55 p.m., Resident #13's room was noted to have a clear plastic bag that was too full and could not be sealed. The bag was not labeled to identify when it was safe to open. - A follow-up tour with the administrator on 11/16/10 revealed the following: - At 10:00 a.m., Resident #98 had a clear plastic bag in her room containing stuffed animals and flower arrangements. The bag had no label identifying when it was safe to open. The administrator stated, ""I swear everything was labeled."" At 10:15 a.m., Resident #40 had a clear plastic bag full of personal items stuffed under her bed. The bag was torn, and loose items were out on the floor. The bag, which was also not labeled, was identified to the administrator. - The action item of bagging all unwashable personal items for a period of seven (7) days was not fully implemented as required by facility policy. -- b) Interview with the director of nursing (DON), on 11/17/10 at 10:15 a.m., revealed the facility recently had an outbreak of scabies among both staff and residents. When asked how many individuals were affected, she reported one (1) resident and one (1) employee were actually diagnosed with [REDACTED]. Review of the infection control monthly line listing revealed three (3) residents who were identified with a rash. Review of facility documentation revealed the administrator, on 11/5/10 at 1:30 p.m., notified the county health department of a confirmed case of scabies. (Resident #103 was sent to a dermatologist on 11/01/10, where he was biopsied, and he was confirmed to have scabies at 11:27 a.m. on 11/04/10.) At first, the facility treated only seventeen (17) residents on one (1) unit. On 11/09/10 at approximately 10:45 a.m., the facility again contacted the local health department (LHD) to report they identified another resident with a rash on another unit. According to facility's ""Scabies Case / Contact Line-Listing Form: Patients: "" submitted to the LHD on 11/09/10, the facility reported having five (5) residents with a rash (#103, #92, #86, #5, and #116); these cases were identified between 11/01/10 and 11/08/10. According to the facility's ""Scabies Cleaning Timeline - 11/5/10"", the following timeline of actions was to be implemented: 11/05/10: - Contact families for 100 hall - Bag all clothes and wash clothes for 100 Hall - Bag all non-washable items for seven (7) days for 100 Hall - Cream ([MEDICATION NAME]) patients on 100 hall 11/06/10: - Shower the 100 Hall residents - Clean 100 hall rooms 11/09/10: - Contact the remaining of North families - Bag all clothes and wash clothes for North - Bag all non-washable items for 7 days for North - Cream patients on North 11/10/10: - Shower the remaining of North Residents - Clean the remaining of the North rooms - Contact Families on TCU - Bag all clothes and wash clothes for TCU - Cream patients on TCU - Vacuum Floors 11/11/10: - Give the Med Ivermectin for TCU and North - Clean the TCU rooms - Rewash 100 Hall clothes - Contact Families on South - Bag all clothes and wash clothes for South - Bag all non-washable items for 7 days for South - Vacuum floors 11/12/10: - Give the Med Ivermectin for South residents - Clean the South rooms - Clean all Dining Room Chairs and Dining Rooms - Vacuum Floors - The action item of simultaneously treating all persons affected (including all symptomatic and asymptomatic health care workers, visitors, volunteers, family members, roommate, and anyone who had skin-to-skin contact with the resident) when the first case of scabies was confirmed was not implemented as required by facility policy. -- c) During an interview on 11/16/10 at 11:35 a.m., the administrator stated all residents and staff were administered Ivermectin by mouth on 11/12/10, with the exception of three (3) employees. One (1) was pregnant and chose to see her physician instead; the other two (2) employees received the topical cream [MEDICATION NAME]. - An Internet search regarding the use of oral Ivermectin to treat scabies infections revealed the following article published in the American Family Physician (the peer reviewed journal for the American Academy of Family Physicians): ""Oral ivermectin is an effective and cost-comparable alternative to topical agents in the treatment of [REDACTED]. Oral dosing may be more convenient in institutional outbreaks and in the treatment of [REDACTED].S. Food and Drug Administration has not approved the drug for the treatment of [REDACTED]."" (Source: http://www.aafp.org/afp/2003/0915/p1089.html Am Fam Physician. 2003 Sep 15;68(6):1089-1092.) .",2014-04-01
11379,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2010-12-09,520,F,,,3ZOF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's infection control policies and procedures related to scabies, review of other facility documentation, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to implement appropriate plans of action to prevent the spread and re-infestation of scabies when a resident was diagnosed with [REDACTED]. The facility was aware of potential quality deficiencies associated with the implementation of policies and procedures to prevent the spread of scabies, as the facility was previously cited for non-compliance related to the facility's failure to respond appropriately to an outbreak of scabies during a complaint investigation completed on 06/16/10. These practices had the potential to result in more than minimal harm to all residents. Facility census: 115. Findings include: a) Observations, during a tour of the facility beginning on 11/15/10 at 7:15 p.m., found several open clear plastic bags in residents' rooms throughout the facility. In an interview on 11/15/10 at 7:15 p.m., a nursing assistant (Employee #145) confirmed the facility had an outbreak of scabies. Employee #145 stated, ""We are to leave all the residents' personal items that cannot be washed in a sealed plastic bag for 7 days. November 19th will be the last day."" The bags, when examined, were not labeled to instruct staff, residents, and/or visitors to not open them until a certain date had come to pass, nor was there any way to determine whether the items in the bags had remained contained for a period of at least seven (7) days. The nursing assistants, when questioned about these bags, confirmed they had to remain sealed until seven (7) days after they were originally bagged. - According to the facility's policy titled ""4.12 Scabies"" (last revised on 02/01/10), the following process was to be implemented: ""5 - Implement procedures to eliminate infestation and prevent transmission to others. ""5.1 - Use Contact Precautions until 24 hours after treatment is administered. ... ""5.2 - Simultaneously treat all persons affected. All symptomatic health care workers, visitors, volunteers, and their contacts should be treated. Asymptomatic family members, roommate, and anyone who has had skin to skin contact with the patient should also be treated. ""5.2.1. - Develop a contact list to identify all persons who had direct physical contact with the patient and their contacts. ... ""5.4 - Place unwashable items (shoes, slippers, pillows, stuffed animals, etc.) in a plastic bag and keep sealed for seven days. ""5.4.1 - Label bag 'Do Not Open until ____ (date).'"" - Subsequent observations during tour of the facility with the administrator (Employee #68) on 11/15/10 found the following: - At 7:45 p.m., Resident #36 was rummaging through a clear plastic bag on the floor of her room. There was no label attached to the bag to identify that the bag should not be opened until a specific date. Resident #36 had over ten (10) clear plastic bags full of unwashable items in the corner of her room with no labels. - At 7:55 p.m., Resident #13's room was noted to have a clear plastic bag that was too full and could not be sealed. The bag was not labeled to identify when it was safe to open. - A follow-up tour with the administrator on 11/16/10 revealed the following: - At 10:00 a.m., Resident #98 had a clear plastic bag in her room containing stuffed animals and flower arrangements. The bag had no label identifying when it was safe to open. The administrator stated, ""I swear everything was labeled."" At 10:15 a.m., Resident #40 had a clear plastic bag full of personal items stuffed under her bed. The bag was torn, and loose items were out on the floor. The bag, which was also not labeled, was identified to the administrator. - The action item of bagging all unwashable personal items for a period of seven (7) days was not fully implemented as required by facility policy. -- b) Interview with the director of nursing (DON), on 11/17/10 at 10:15 a.m., revealed the facility recently had an outbreak of scabies among both staff and residents. When asked how many individuals were affected, she reported one (1) resident and one (1) employee were actually diagnosed with [REDACTED]. Review of the infection control monthly line listing revealed three (3) residents who were identified with a rash. Review of facility documentation revealed the administrator, on 11/5/10 at 1:30 p.m., notified the county health department of a confirmed case of scabies. (Resident #103 was sent to a dermatologist on 11/01/10, where he was biopsied, and he was confirmed to have scabies at 11:27 a.m. on 11/04/10.) At first, the facility treated only seventeen (17) residents on one (1) unit. On 11/09/10 at approximately 10:45 a.m., the facility again contacted the local health department (LHD) to report they identified another resident with a rash on another unit. According to facility's ""Scabies Case / Contact Line-Listing Form: Patients:"" submitted to the LHD on 11/09/10, the facility reported having five (5) residents with a rash (#103, #92, #86, #5, and #116); these cases were identified between 11/01/10 and 11/08/10. According to the facility's ""Scabies Cleaning Timeline - 11/5/10"", the following timeline of actions was to be implemented: 11/05/10: - Contact families for 100 hall - Bag all clothes and wash clothes for 100 Hall - Bag all non-washable items for seven (7) days for 100 Hall - Cream ([MEDICATION NAME]) patients on 100 hall 11/06/10: - Shower the 100 Hall residents - Clean 100 hall rooms 11/09/10: - Contact the remaining of North families - Bag all clothes and wash clothes for North - Bag all non-washable items for 7 days for North - Cream patients on North 11/10/10: - Shower the remaining of North Residents - Clean the remaining of the North rooms - Contact Families on TCU - Bag all clothes and wash clothes for TCU - Cream patients on TCU - Vacuum Floors 11/11/10: - Give the Med Ivermectin for TCU and North - Clean the TCU rooms - Rewash 100 Hall clothes - Contact Families on South - Bag all clothes and wash clothes for South - Bag all non-washable items for 7 days for South - Vacuum floors 11/12/10: - Give the Med Ivermectin for South residents - Clean the South rooms - Clean all Dining Room Chairs and Dining Rooms - Vacuum Floors - The action item of simultaneously treating all persons affected (including all symptomatic and asymptomatic health care workers, visitors, volunteers, family members, roommate, and anyone who had skin-to-skin contact with the resident) when the first case of scabies was confirmed was not implemented as required by facility policy. -- c) In a written statement provided by the DON on 11/17/10, the facility held their last quarterly QAA committee meeting on 07/02/10. During that meeting, the committee discussed the procedures to be taken in a scabies outbreak. One (1) item listed on the written statement was that the facility would bag all items in resident rooms, label, and date them for when the bags are to be opened. The facility did not list a monitoring action to ensure that all procedures were implemented during a scabies outbreak.",2014-04-01
11380,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2010-12-09,309,G,,,3ZOF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on incident report review, medical record review, staff interview, and family interview, the facility failed to ensure one (1) of nine (9) sampled residents received prompt medical attention following a fall from bed. The facility failed to contemporaneously collect and record physical assessment data following a fall (to identify possible injuries), failed to immediately notify the resident's family and physician of the fall, failed to communicate the fall to oncoming shifts so that staff would know to monitor the resident for possible sequelae of the fall, and failed to assess / monitor the resident after the fall to identify the need for, and obtain, medical intervention until after a family member intervened. On 10/16/10 at approximately 9:00 p.m., Resident #100 was said to have ""slithered"" out of her bed and onto the floor unassisted. The licensed practical nurse (LPN) who observed the incident (Employee #128) did not complete an incident report or document anything about the event in the resident's medical record at the time of the occurrence. She generated a ""late entry"" nursing note and an incident report (both dated 10/16/10), stating Resident #100 had no apparent injury related to the fall and no complaints of pain. When interviewed, Employee #128 admitted to not having completed a thorough assessment after the fall occurred on 10/16/10, and she admitted to not having documented anything about this fall (on either an incident report or in the nursing notes) until after the family's visit, which occurred on the evening of 10/17/10. No contemporaneous entries were made in the resident's nursing notes about Resident #100 having an injury until 6:20 p.m. on 10/17/10, when the nurse on duty at that time (Employee #34) recorded that the resident's son found a bruise on the resident's right shoulder that was dark purple in color; when interviewed, Employee #34 reported she had not been aware of the fall on 10/16/10 at the bruising was discovered by the family. This bruise, which extended from her neck, across her shoulder, and down her right arm, was readily visible to the family (as the resident was wearing a hospital gown), and it was turning black in color when found by the family on 10/17/10. The facility had no knowledge of this bruise until the family brought it to their attention. Only after the son intervened, did the facility contact the physician, and Resident #100 was later diagnosed with [REDACTED]. Although it could not be ascertained whether the fracture was sustained during the fall on 10/16/10, during the transfer back to bed after the fall on 10/16/10, or during a fall that occurred at an earlier date, the facility failed to identify the presence of the injury and obtain medical intervention until after the resident's family intervened. Resident identifier: #100. Facility census: 115. Findings include: a) Resident #100 1. Review of facility records, conducted on 11/16/10 at approximately 11:00 a.m., revealed an incident report dated 10/16/10 for an event said to have occurred at 9:00 p.m. on 10/16/10 involving Resident #100. The report stated, ""As I was starting up the hallway to do my med pass, Heard (sic) resident in Rm (#) yelling out. When (sic) entered the room and walked to her side (sic). She already started out of bed on her arms before I get (sic) to her; the bottom half slithered out. Asked resident if she could get up and she attempted but went down on her right side. Low bed and mats (sic)."" This report, which was signed as having been prepared by Employee #128 on 10/16/10, contained no assessment information in the section titled ""Initial Assessment"", which prompted the assessor to record information such as vital signs and an examination for any changes in the resident's range of motion. -- 2. Review of the resident's electronic medical record revealed the following consecutive entries in the nursing progress notes: - An entry dated 10/15/10 at 19:03 (7:03 p.m.) written by Employee #43, a registered nurse (RN) - ""Skin assessment performed per orders. New skin tear on rt (right) knee where pt (patient) scraped off a scab. ... Pt has dry,cracked (sic) skin around her mouth which had bled a few times today ... Pt has small healing bruise on rt upper back. ... Lt (left) heel wound continues to improve."" - An entry dated 10/16/10 at 21:00 (9:00 p.m.) identified as being a ""late entry"", written by Employee #128, an LPN - ""As I was starting up the hallway to do my med pass. (sic) Write heard resident yelling out. When (sic) entered the room and walked to her side. (sic) She already started out of the bed on her arms before I could get to her; the bottom half (sic) slithered out and unto (sic) the mat. Asked resident if she could get up (sic) and she attempted but went down onto her right side. I then went out and got CNA's (certified nursing assistants) to help assist her back into bed. When I had given the resident her meds (sic) which I had already had in the room with me at the time. (sic) I assessed resident and did not see any injuries at this time. Resident did not complain of any pain nor (sic) distress noted."" - An entry dated 10/17/10 at 18:20 (6:20 p.m.) written by Employee #34, an LPN - ""At 5pm (sic) son reported to this nurse that he found a bruise on residents (sic) shoulder. This nurse noted bruise to right shoulder dark purple in color. Tylenol administered as ordered prior to family arriving. Family requested to speak with administrator and called his cell phone. Paged Dr. (name) and obtained stat order for xray (sic) to right shoulder. Called quality (sic) Mobile with new order. Administrator and DON (director of nursing) came in and talked with the family. Family then requested that resident be sent to ER for xray (sic). B/P 123/69 Temp 98.6 R18 P87 o2 sats 95%. Called (ambulance company name) but had (sic) no ambulance available. Called 911 for transport to ER. Resident left facility at 6:20 pm."" - An entry dated 10/17/10 at 23:46 (11:46 p.m.) written by Employee #27, an LPN - ""resident (sic) returned to facility at this time, via ambulance stretcher alone ... received report from d/c (discharging) nurse at (name of hospital), she stated she (the resident) has a FX (fracture) to her right clavicle ..."" There were no entries between the note identified as a ""late entry"" dated 10/16/10 at 9:00 p.m. and the note dated 10/17/10 at 6:20 p.m.; there was no evidence the licensed nursing staff of this facility contemporaneously collected and recorded any physical assessment data for this resident after she fell on [DATE] and leading up to the time the resident's family found the dark purple bruise on the resident's right shoulder. -- 3. A review of the nursing notes after the resident's return to the facility on [DATE] revealed an entry dated 10/18/10 at 08:47 (8:47 a.m.), written by Employee #34, stating, ""Late entry for 10/17/2010. During med pass at 10am (sic) this nurse ask (sic) resident if she was having any pain. Resident denied pain. Resp (respirations) even and unlabored. No signs of pain or discomfort noted. Resident was lying on back and was awake. At 12p (sic) administered prescribed dose of Tylenol (sic) and ask (sic) resident again if she had any pain and she denied pain. Administrated schelduled (sic) medication at 2:30pm (sic) and resident was resting quietly in bed and showed no signs of pain or discomfort. At 4p (sic) checked residents (sic) blood sugar and she was turned on her side and she asked for a drink of water. No signs of pain or discomfort noted and no facial grimace noted. Ask (sic) resident how if (sic) she was feeling ok and she stated she was 'fine'."" All of this information was entered into the record on the morning after the resident returned from the hospital, after having been diagnosed with [REDACTED]. -- 4. review of the resident's medical record revealed [REDACTED]. According to her most recent comprehensive assessment (for a significant change in status) with an assessment reference date (ARD) of 08/16/10, Resident #100 was described as being alert and disoriented with short and long-term memory problems and moderately impaired cognitive skills for daily decision-making. She was also described as requiring limited assistance with bed mobility and transfers. According to her most recent full assessment (a Medicare re-admission / return assessment) with an ARD of 09/26/10, her cognitive status remained unchanged, she was now totally dependent on staff for all activities of daily living (including bed mobility and transfers), and a test for standing balance could not be attempted at that time. Review of the resident's care plan revealed a problem statement related to the resident's risk for complications associated with diabetes. The first intervention listed to address this problem was: ""Assess skin integrity daily with care and report abnormalities."" Review of the resident's activities of daily living (ADL) flowsheet for October 2010 revealed the nursing assistants documented having provided assistance to Resident #100 with ADLs as follows: 10/16/10 on evening shift - total dependence for transferring by two (2) nursing assistants; total dependence with bathing (partial bed bath); extensive physical assistance with dressing by two (2) nursing assistants; and total dependence for personal hygiene by one (1) nursing assistant. 10/16/10 on night shift - extensive physical assistance for transferring by two (2) nursing assistants; extensive physical assistance for bathing by two (2) nursing assistants (sponge / bed bath); and total dependence with dressing by one (1) nursing assistant. No information was available about any ADL assistance that had been provided on the day shift of 10/17/10 (the places to record this were left blank), and no information was available any ADL assistance provided on the evening shift, because staff recorded ""OOF"" (out of facility) for the entire shift, even though the resident was not transferred to the hospital until 6:20 p.m. on 10/17/10. (See also citation at F514.) The performance of transferring, dressing , bathing, and/or personal hygiene on these shifts for this dependent resident would have provided opportunities for staff to have observed bruising as it developed on the resident's right neck, shoulder and upper arm, especially while she was wearing a hospital gown (as had been observed by the family on the evening of 10/17/10). -- 5. Review of an ""unusual occurrence"", self-reported by the administrator to the State survey and certification agency on 10/18/10, revealed the following: ""On 10/17/10 MPOA of (Resident #100) had a concern about the bruise on her left shoulder and questioned if it was fractured. The administrator was notified by the MPOA that he needed to see it. (Note: The reference to the left shoulder appears to be a mistake as the nursing note for 10/17/10 reflected the son found a bruise on the resident's right shoulder.) ""The Resident (sic) is DNR (do not resuscitate), limited treatment, Hospice. Has a history of multiple falls related to behavior issues (sic). According to physician determination of capacity, the resident lacks capacity to make her own healthcare decisions due to Dementia, Stage 7. ""On 10/16/10 at approximately 9:00pm (sic) the resident was observed to have been 'slithering out and onto the mat. Asked resident if she could get up and as she attempted went down onto her right side. Resident was assessed and the nurse did not see any injuries at this time. Resident did not complain of any pain nor distress noted. (No quotation mark was present to indicate where the quoted material ended.) ""During med pass at 10am (sic) on 10/17/10, the nurse asked resident if she was having any pain. Resident denied pain. Respirations were even and unlabored. No signs of pain or discomfort noted. Resident was lying on back and was awake. At 12p (sic) administered prescribed does of Tylenol and ask resident again if she had any pain and she denied pain. Administered scheduled medication at 2:30 pm and resident was resting quietly in bed and showed no signs of pain or discomfort. At 4p (sic) checked residents (sic) blood sugar and she was turned on her side and she asked for a drink of water. No signs of pain or discomfort noted and no facial grimace noted. Asked resident if she was feeling ok and she stated she was 'fine.' ""On 10/17/10 at approximately 5:30pm (sic) the family visited and voiced concerns and wanted her to be sent to the Hospital (sic) for an evaluation. The Clavicle (sic) was fractured. The resident was returned to the facility with continued meds. Resident is being observed and monitored."" -- 6. A telephone interview with the administrator, on 12/08/10 at approximately 9:30 a.m., revealed Resident #100 received hospice services. She had a physician's orders [REDACTED]."" According to the administrator, Hospice Care had ordered this, because the family felt the multiple falls the resident was having may have been related to her having untreated pain. The administrator also said he had observed the resident, after the family contacted him on the evening of 10/17/10, and did not find her to be in any pain. -- 7. During a telephone interview on 12/08/10 at approximately 12:15 p.m., the resident's family member stated they came to the facility to visit on 10/17/10. At that time, they had not visited in approximately two (2) days. They discovered Resident #100 had a large bruise on the back of her neck which extended down her right arm. This bruise was readily visible to the family (as the resident was wearing a hospital gown) and was described as turning black in color. The family brought this to the attention of the administrator and nursing staff, who denied seeing it prior to the family bringing it to their attention. (See also citation at F157.) -- 8. The facility was re-entered on 12/09/10, in order for the surveyor to collect additional information regarding the resident's fall and subsequent identification and treatment of [REDACTED].#100 had the following documented events in the days prior to 10/16/10: - 10/01/10 at 6:45 p.m. - ""Resident was in shower room with CNA when CNA attempted to stand resident to dry her off. When CNA was drying resident, resident decided to sit on floor. Resident was lowered to floor by CNA."" - 10/10/10 at 3:00 p.m. - ""Resident sitting in WC (wheelchair); went to stand up to go to room. She went down to the floor."" - 10/11/10 at 10:30 a.m. - ""Resident sitting in w/c (wheelchair) in hallway by nurses (sic) station - noted to roll out of w/c to floor."" - 10/11/10 at 11:15 a.m. - ""Resident noted to be scratching at right forearm then scab noted in hand - bleeding noted from right forearm."" - 10/11/10 at 3:00 p.m. - ""Resident found curled up on safety mat next to bed. Stated 'I'm hiding they are going to kill me.' When asked if she fell or climbed she stated she climbed to hide from people trying to kill her. "" - 10/12/10 at 8:45 a.m. - ""Pt (patient) was sitting in wheelchair in dining room requesting to 'go to Bed'. Pt was informed it would be a few minutes. Then pt leaned forward and fell on to floor."" - 10/13/10 at 5:15 p.m. - ""Resident was sitting at nurses (sic) station in w/c when resident put herself in the floor. When asked why she stated she was hiding cause (sic) they were gonna kill her."" The director of nursing (DON) reported, at about 11:45 a.m. on 12/09/10, that most of the time Resident #100 did not have any injuries from these incidents but that bruising would appear later. -- 9. Employee #128, when interviewed on 12/09/10 at approximately 12:30 p.m., reported she had worked as Resident #100's nurse on the night of 10/16/10. She said she had responded to the resident's hollering out and, when she entered the room, the resident was coming out of the bed arms first; before she could intervene, the resident had ""slithered"" the bottom half of her body onto the mat. Following this, she went to get assistance from two (2) nurse aides (Employees #29 and #129). Employee #128 reported she believed the three (3) of them used a sheet to transfer the resident back into her bed; however, she was not positive that this was how the transfer back to the bed occurred. Employee #128 stated she did not consider this event a ""fall"" and, as a result, she did not complete an incident / accident report at the time of the occurrence. She commented that she later was disciplined for not doing so. Employee #128 admitted that she had not documented anything about Resident #100's fall that occurred on the evening of 10/16/10 until the family became upset. (The family was noted by Employee #34 to have discovered the bruise during a visit that began around 5:00 p.m. on 10/17/10.) (NOTE: According to Appendix PP of the State Operations Manual promulgated by the Centers for Medicare & Medicaid Services, ""'Fall' refers to unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred."") Employee #128 commented that she guessed she just forgot to fill out the top initial assessment portion on the report. This section was left blank. She said she asked the resident if she was hurt, and the resident said she was not. She also said she asked the resident if she was in pain, and the resident denied that as well. Employee #128 said she had a concern that the resident may have injured her hip. This concern was due to the fact that she had asked the resident if she could get up after the fall and the resident tried but landed on her right side. The LPN said she assessed the resident's right hip by applying pressure to the area to see if the resident expressed experiencing pain; the resident did not. She denied physically assessing any other part of the resident's right side, and she did not perform any range of motion exercise to any areas on the resident's right side to check for injuries. Employee #128 said she was aware the resident had a bruise to her right shoulder from a previous fall. -- 10. Employee #129 was interviewed by telephone at approximately 1:00 p.m. on 12/09/10; he no longer worked at the facility. He confirmed that he assisted the LPN with getting the resident back to bed on 10/16/10; he said he thought they picked the resident up under her arms to get her back into bed. He reported having no other knowledge of anything pertaining to the fall. -- 11. Employee #34 was interviewed by telephone on the early afternoon on 12/09/10. She acknowledged she was the LPN assigned to work with Resident #100 on 10/17/10, and that she was at the facility when the resident's family arrived and questioned the bruise on the resident's shoulder. She reported she did not know how the bruise got there, but she told the family she thought the resident had fallen on 10/15/10. She stated she told the family they would probably get faster results from having a mobile imaging company perform the x-ray on the resident's shoulder but the family insisted on having the resident sent out to a local emergency room . She related that Employee #128 did not tell her anything about the resident falling on 10/16/10 when she reported to work at 7:00 a.m. on 10/17/10. Employee #34 said Resident #100 acted very pleasant on during the day on 10/17/10. She reported she always asks the residents if they are in pain and said Resident #100 denied being in pain. -- 12. The DON and administrator acknowledged that Employee #128 failed to thoroughly assess Resident #100 following the fall on 10/16/10. However, the DON and administrator reported their beliefs that the facility had provided quality care to the resident and that staff had mainly failed to document their assessments and findings .",2014-04-01
11381,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2010-12-09,514,D,,,3ZOF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, family interview, and review of the 2009 long-term care (LTC) documentation guidelines published by the American Health Information Management Association (AHIMA), the facility failed to ensure the medical record of one (1) of nine (9) sampled residents was maintained in accordance with accepted standards of professional practice. Resident #100 was observed by a licensed practical nurse (LPN) having ""slithered"" out of her bed and onto the floor on the evening of 10/16/10. The LPN who witnessed this occurrence (Employee #128), when interviewed on 12/09/10, reported that she did not record an entry in the resident's nursing notes when the event occurred; rather, she recorded an entry in the nursing notes after the family noticed extensive bruising on the resident's shoulder during a visit on the evening of 10/17/10. The note, which was identified as a ""late entry"" and dated 10/16/10 at 21:00 (9:00 p.m.), did not contain any information to alert the reader that it was actually recorded after the fact, at a later date and time. Additionally, review of the resident's activities of daily living (ADL) flowsheet for October 2010 revealed blanks where the assigned nursing assistant should have recorded the amount of ADL assistance provided to the resident on the day shift (7:00 a.m. to 3:00 p.m.) on 10/17/10, and staff recorded ""OOF"" (out of facility) for the evening shift (3:00 p.m. to 11:00 p.m.) on 10/17/10, even though she did not leave the facility until 6:20 p.m. on that date. According to this resident's most recent minimum data set assessment, she was totally dependent on staff for all ADLs. Resident identifier: #100. Facility census: 115. Findings include: a) Resident #100 1. Review of facility records, conducted on 11/16/10 at approximately 11:00 a.m., revealed an incident report dated 10/16/10 for an event said to have occurred at 9:00 p.m. on 10/16/10 involving Resident #100. The report stated, ""As I was starting up the hallway to do my med pass, Heard (sic) resident in Rm (#) yelling out. When (sic) entered the room and walked to her side (sic). She already started out of bed on her arms before I get (sic) to her; the bottom half slithered out. Asked resident if she could get up and she attempted but went down on her right side. Low bed and mats (sic)."" This report was signed as having been prepared by Employee #128 on 10/16/10. -- 2. Review of the resident's electronic medical record revealed the following consecutive entries in the nursing progress notes: - An entry dated 10/15/10 at 19:03 (7:03 p.m.) written by Employee #43, a registered nurse (RN) - ""Skin assessment performed per orders. New skin tear on rt (right) knee where pt (patient) scraped off a scab. ... Pt has dry,cracked (sic) skin around her mouth which had bled a few times today ... Pt has small healing bruise on rt upper back. ... Lt (left) heel wound continues to improve."" - An entry dated 10/16/10 at 21:00 (9:00 p.m.) identified as being a ""late entry"", written by Employee #128, an LPN - ""As I was starting up the hallway to do my med pass. (sic) Write heard resident yelling out. When (sic) entered the room and walked to her side. (sic) She already started out of the bed on her arms before I could get to her; the bottom half (sic) slithered out and unto (sic) the mat. Asked resident if she could get up (sic) and she attempted but went down onto her right side. I then went out and got CNA's (certified nursing assistants) to help assist her back into bed. When I had given the resident her meds (sic) which I had already had in the room with me at the time. (sic) I assessed resident and did not see any injuries at this time. Resident did not complain of any pain nor (sic) distress noted."" - An entry dated 10/17/10 at 18:20 (6:20 p.m.) written by Employee #34, an LPN - ""At 5pm (sic) son reported to this nurse that he found a bruise on residents (sic) shoulder. This nurse noted bruise to right shoulder dark purple in color. Tylenol administered as ordered prior to family arriving. Family requested to speak with administrator and called his cell phone. Paged Dr. (name) and obtained stat order for xray (sic) to right shoulder. Called quality (sic) Mobile with new order. Administrator and DON (director of nursing) came in and talked with the family. Family then requested that resident be sent to ER for xray (sic). B/P 123/69 Temp 98.6 R18 P87 o2 sats 95%. Called (ambulance company name) but had (sic) no ambulance available. Called 911 for transport to ER. Resident left facility at 6:20 pm."" - An entry dated 10/17/10 at 23:46 (11:46 p.m.) written by Employee #27, an LPN - ""resident (sic) returned to facility at this time, via ambulance stretcher alone ... received report from d/c (discharging) nurse at (name of hospital), she stated she (the resident) has a FX (fracture) to her right clavicle ..."" There were no entries between the note identified as a ""late entry"" dated 10/16/10 at 9:00 p.m. and the note dated 10/17/10 at 6:20 p.m.; there was no evidence the licensed nursing staff of this facility contemporaneously collected and recorded any physical assessment data for this resident after she fell on [DATE] and leading up to the time the resident's family found the dark purple bruise on the resident's right shoulder. (See also citation at F309.) - According to the 2009 AHIMA LTC documentation guidelines, in the section titled ""5. Legal Documentation Standards"": ""9. Completeness - Document all facts and pertinent information related to an event, course of treatment, resident condition, response to care and deviation from standard treatment (including the reason for it). Make sure entry is complete and contains all significant information. If the original entry is incomplete, follow guidelines for making a late entry, addendum or clarification."" - ""20. Incidents - When an incident occurs, document the facts of the occurrence in the progress notes. Do not chart that an incident report has been completed or refer to the report in charting."" -- 3. During a telephone interview on 12/08/10 at approximately 12:15 p.m., the resident's family member stated they came to the facility to visit on 10/17/10. At that time, they had not visited in approximately two (2) days. They discovered Resident #100 had a large bruise on the back of her neck which extended down her right arm. This bruise was readily visible to the family (as the resident was wearing a hospital gown) and was described as turning black in color. The family brought this to the attention of the administrator and nursing staff, who denied seeing it prior to the family bringing it to their attention. -- 4. The facility was re-entered on 12/09/10, in order for the surveyor to collect additional information regarding the resident's fall and subsequent identification and treatment of [REDACTED]. on 10/16/10 contained no information to alert the reader that the note was not contemporaneously recorded in the electronic medical record at 9:00 p.m. on 10/16/10. Employee #128, when interviewed on 12/09/10 at approximately 12:30 p.m., reported she had worked as Resident #100's nurse on the night of 10/16/10. She said she had responded to the resident's hollering out and, when she entered the room, the resident was coming out of the bed arms first; before she could intervene, the resident had ""slithered"" the bottom half of her body onto the mat. Employee #128 stated she did not consider this event a ""fall"" and, as a result, she did not record an entry in the resident's medical record or generate an incident / accident report at the time of the occurrence. She commented that she later was disciplined for not doing so. Employee #128 admitted that she had not documented anything about Resident #100's fall that occurred on the evening of 10/16/10 until the family became upset. (The family was noted by Employee #34 to have discovered the bruise during a visit that began around 5:00 p.m. on 10/17/10.) - According to the 2009 AHIMA LTC documentation guidelines, in the section titled ""5. Legal Documentation Standards"": ""3. Date and Time on Entries ""3.1. Timeliness of Entries - Entries should be made as soon as possible after an event or observation is made. An entry should never be made in advance. If it is necessary to summarize events that occurred over a period of time (such as a shift), the notation should indicate the actual time the entry was made with the narrative documentation identifying the time events occurred if time is pertinent to the situation. ""3.2. Pre-dating and back-dating - It is both unethical and illegal to pre-date or back-date an entry. Entries must be dated for the date and time the entry is made. (See section on late entries, addendum, and clarifications). If pre-dating or back-dating occurs it is critical that the underlying reason be identified to determine whether there are system failures. The cause must be evaluated and appropriate corrective action implemented."" - ""24. Omissions in Documentation - At times it will be necessary to make an entry that is late (out of sequence) or provide additional documentation to supplement entries previously written. ""0. Making a Late Entry - When a pertinent entry was missed or not written in a timely manner, a late entry should be used to record the information in the medical record. ""1. Identify the new entry as a 'late entry'. ""2. Enter the current date and time - do not try to give the appearance that the entry was made on a previous date or an earlier time. ""3. Identify or refer to the date and incident for which (sic) late entry is written. ""4. If the late entry is used to document an omission, validate the source of additional information as much as possible (where did you get information to write late entry). For example, use of supporting documentation on other facility worksheets or forms. ""5. When using late entries (sic) document as soon as possible. There is not a time limit to writing a late entry, however, the more time that passes the less reliable the entry becomes."" -- 5. According to her most recent comprehensive assessment (for a significant change in status) with an assessment reference date (ARD) of 08/16/10, Resident #100 was described as being alert and disoriented with short and long-term memory problems and moderately impaired cognitive skills for daily decision-making. She was also described as requiring limited assistance with bed mobility and transfers. According to her most recent full assessment (a Medicare re-admission / return assessment) with an ARD of 09/26/10, her cognitive status remained unchanged, and she was now totally dependent on staff for all activities of daily living (including bed mobility and transfers). Review of the resident's ADL flowsheet for October 2010 revealed the nursing assistants documented having provided assistance to Resident #100 with ADLs as follows: - No information was available about any ADL assistance that had been provided on the day shift of 10/17/10 (the places to record this were left blank), and - No information was available any ADL assistance provided on the evening shift, because staff recorded ""OOF"" (out of facility) for the entire shift. This dependent resident was not transferred to the hospital until 6:20 p.m. on 10/17/10 and would have been present to receive ADL assistance from staff throughout the entire day shift and a portion of the evening shift on 10/17/10.",2014-04-01
2259,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2019-03-27,623,D,0,1,TD9H11,"Based on record review and staff interview, the facility failed to ensure a resident or the resident's responsible party was notified of the resident's transfer to a hospital for medical treatment. This deficient practice affected one (1) of four (4) residents reviewed for hospitalization . Resident identifier: #40. Facility census: 105. Findings included: a) Resident #40 A review of Resident #40's medical record on 03/26/19 at 8:05 AM revealed that Resident #40 had been transferred to a hospital for medical treatment on 01/03/19 and 03/22/19. No written notification to Resident #40 or Resident #40's responsible party regarding the transfer was found in the medical record, so copies of written notification were requested from administration. On 03/26/19 at 11:44 AM, the facility's Assistant Administrator provided information regarding the documentation that was sent to the hospital with Resident #40, but not written notification to Resident #40 or Resident #40's responsible party regarding the transfer. On 03/27/19 at 10:55 AM, the facility's Assistant Administrator stated that the facility did not notify Resident #40 or Resident #40's responsible party in writing of the reason for Resident #40's transfer to the hospital on either 01/03/19 or 03/22/19. The facility's Assistant Administrator stated that Resident #40's responsible party had been called, but not notified of the reasons for the transfer in writing as required.",2020-09-01
2260,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2019-03-27,641,D,0,1,TD9H11,"Based on record review and staff interview, the facility failed to accurately complete section A of the Minimum Data Set (MDS) to indicate where a resident was transferred after their discharge from the nursing facility. This deficient practice affected one (1) of 24 sampled residents. Resident identifier: #111. Facility census: 105. Findings included: a) Resident #111 A review of Resident #111's medical record on 03/26/19 at 10:33 AM revealed that Resident #111 was transferred to another nursing facility on 01/29/19. A review of Resident #111's discharge MDS with an Assessment Reference Date (ARD) of 01/29/19 revealed that section A of the MDS had been incorrectly coded for discharge to an acute hospital instead of discharge to another nursing facility. On 03/26/19 at 10:57 AM, MDS Coordinator #8 acknowledged that section A had been coded incorrectly and stated that the MDS would be corrected and resubmitted. The facility's Assistant Administrator acknowledged the inaccurate MDS on 03/27/19 at 8:37 AM.",2020-09-01
2261,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2019-03-27,684,D,0,1,TD9H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, 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. The facility failed to obtain laboratory testing according to the physician's orders [REDACTED]. Resident identifier: #17. Facility census: 105. Findings included: a) Resident #17 Resident #17 had an order written [REDACTED]. The monthly laboratory testing ordered was a basic metabolic panel (BMP), which measured the glucose level, kidney function, and electrolyte and fluid balance, and a B-type natriuretic peptide (BNP), which measured [MEDICAL CONDITION]. Review of Resident #17's medical records revealed laboratory testing was obtained on 10/15/18 and 12/07/18. The medical records did not contain BMP and BNP testing for (MONTH) (YEAR). During an interview on 03/26/19 at 1:51 PM, Registered Nurse (RN) #67 confirmed Resident #17 did not have laboratory testing in (MONTH) (YEAR). RN #67 stated on 12/07/18, Resident #17's physician was notified monthly laboratory testing had not been performed in (MONTH) (YEAR), and the testing was performed that day. Review of laboratory testing results revealed Resident #17's BMP and BNP results were essentially the same on 10/15/18 and 12/07/18. On 03/27/19 at 8:45 AM, the Assistant Administrator was notified of the above finding. No further information was provided through the completion of the survey.",2020-09-01
2262,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2019-03-27,697,D,0,1,TD9H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility failed to assess the resident's pain before and after the administration of as needed pain medication for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identified: #110. Facility census: 105. Findings included: 1) Resident #110 Resident #110 had a [MEDICAL CONDITION] which occurred during a fall on 03/19/19. She had an order for [REDACTED]. Review of Resident #110's Medication Administration Record [REDACTED]. The facility's Pain Management Policy stated, The pain assessment flow sheet will be filled out every time a PRN pain medication is administered . The pain assessment flow sheet contained an assessment of the site or location of pain, the type of pain, the current pain intensity, precipitating or aggravating factors, non-medication interventions attempted, the medication and dose administered, medication side-effects experienced, and the intensity of the pain 15 minutes, 30 minutes, one (1) hour, and three (3) hours after the medication was administered. Review of Resident #17's medical records revealed no documentation was made on the resident's Pain Flow Sheet on four (4) of the 14 occasions as needed pain medications were administered from 03/19/19 through 03/26/19. These occasions were on the following dates and times: 03/24/19 at 10:00 PM, 03/25/19 at 12:00 AM, 03/24/19 at 6:00 PM, and 03/26/19 at 6:00 AM. During an interview on 03/27/19 at 9:43 AM, Registered Nurse (RN) #67 agreed no documentation was made on the Resident 17's Pain Flow Sheet on four (4) of the 14 occasions as needed pain medications were administered from 03/19/19 through 03/26/19. On 03/27/19 at 2:24 PM, the Assistant Administrator was notified of the above finding. No further information was provided through the completion of the survey.",2020-09-01
2263,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2019-03-27,758,D,0,1,TD9H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the order for a prn (as needed) [MEDICAL CONDITION] medication extending beyond 14 days contained the duration of use for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #17. Facility census: 105. Findings included: a) Resident #99 Resident #99 had an order written [REDACTED]. The duration of the order was not indicated. Resident #99 continued to receive as needed Klonopin 0.5 mg every eight (8) hours as needed for pain until 02/20/19. On 02/20/19 an order was written for the resident to receive Klonopin ([MEDICATION NAME]) 0.5 mg by mouth around-the-clock every 12 hours for anxiety. Review of Resident #99's Medication Administration Records (MARs) revealed the resident received as needed Klonopin on 33 occasions in (MONTH) (YEAR) and 30 occasions in (MONTH) 2019. Resident #99 received as needed Klonopin on 24 occasions in (MONTH) before the order was changed to 12 hours around-the-clock. The resident did not receive Klonopin on a daily basis and on some days received two (2) doses. During an interview on 03/27/19 at 12:43 PM, Registered Nurse (RN) #67 agreed Resident #99's as needed Klonopin order did not contain a duration of use. She provided physician progress notes [REDACTED]. A Physician's Progress Note written on 11/02/18 stated, Continue the Klonopin 0.5 mg q (every) 8 hrs as needed for anxiety and agitation. A Physician's Progress Note written on 01/29/19 stated, Anxiety and agitation - started on Klonopin 0.5 mg q 8 hrs prn on 10/29/18. Clinically contraindicated to reduce at this time. Resident continues to have periods of agitation. On 03/27/19 at 2:24 PM, the Assistant Administrator was notified of the above finding. No further information was provided through the completion of the survey.",2020-09-01
2264,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2019-03-27,761,D,0,1,TD9H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to label a multi-use vial in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. This was a random opportunity for discovery while touring the medication storage room, the multi-use vial of [MEDICATION NAME] did not have an opened date and had the potential to affect a limited number of residents. Facility census 105. Findings included: During an interview and observation on 03/27/19 at 9:21 AM, Licensed Practical Nurse #88 verified that an opened, partially used multi vial of [MEDICATION NAME] Purified Protein Derivative (TPPD) did not have a date it to indicate when it was intially opened on the vial. The TPPD has the potential to lose the potency and effectiveness after being opened 30 days and should be discarded. On 03/27/19 at 11:00 AM, Assistant Administrator #4 was informed of findings. Stated she will take care of it.",2020-09-01
2265,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2019-03-27,842,D,0,1,TD9H11,"**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 Medical Administration Record (MAR) for one (1) of six (6) residents reviewed for the care area of unnecessary medications. Resident identifier: #37. Facility census: 105. Findings included: 1) Resident #37 On 10/23/18 at 2:51 PM an order was written for Resident #37 for [MEDICATION NAME] tablet, 2 mg, give 0.5 mg by mouth at bedtime for anxiety. The order stated to give 1/2 tablet to equal 0.5 mg. Also, on 10/23/18 at 2:51 PM an order of clarification of dosage was written for Resident #37 for [MEDICATION NAME] tablet, 2 mg, give 0.5 mg by mouth at bedtime for anxiety. This order stated to give 1/4 tablet to equal 0.5 mg. Review of Resident #37's Medication Administration Record [REDACTED]. Give 1/2 tablet to equal 0.5 mg. Review of Resident #37's Medication Administration Record [REDACTED]. Give 1/4 tablet to equal 0.5 mg. On 03/26/19 at 12:15 PM, Registered Nurse (RN) #67 was shown Resident #37's MAR for (MONTH) (YEAR). RN #67 agreed 1/2 of a 2 mg tablet of [MEDICATION NAME] equaled 1 mg, and not 0.5 mg. She stated she would obtain documentation from the pharmacy who supplied the medication to verify what dosage the resident received. On 03/26/19 at 1:00 PM, RN #67 provided documentation dated 10/23/18 that the pharmacy supplied 1/4 tablets of [MEDICATION NAME] 2 mg to equal 0.5 mg for Resident #37 On 03/27/19 at 8:44 AM, the Assistant Administrator was informed of the above findings. No additional information was provided through the completion of the survey.",2020-09-01
2266,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2019-03-27,880,C,0,1,TD9H11,"Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was true for the laundry room having air flow pulling the air from the soiled side into the clean side and air drying and storing clean items in the soiled laundry room. This failed practice had the potential to have a minimal affect on the residents of the facility. Facility census 105. Findings included: During a tour and interview on 03/27/19 at 8:03 AM, Laundry Employee # 116 was asked to get the Maintenance Supervisor to come to the laundry room. She was asked about the mop heads being dried in the soiled laundry room and the personal items hanging on a clothing rack being stored in the soiled side of the laundry room uncovered. She said, that it was things that did not have names on them and when someone was missing something they would look there to see if the lost items were there. She was asked if the clothing were rewashed before returning them to the residents, and she said no. During a tour and interview on 03/27/19 at 8:07 AM, Maintenance #98 was shown that the air flow from the soiled side was being pulled into the clean side with a tissue paper, Also the suction on the door was very strong pulling the soiled air into the clean side. He alerted Maintenance Supervisor #1 and Maintenance Supervisor Assistant #75 about the problem. They stated the problem was the exhaust fan in the dryer room was pulling the air from the soiled to the clean. They stated that they would fix that immediately. During an interview on 03/27/19 at 8:17 AM, Housekeeping Supervisor #72 about the storing clean items of clothing and drying mop heads in the soiled laundry room. She voiced understanding and had the items removed. During a brief interview on 03/27/19 at 9:00AM, Maintenance Supervisor #1 stated that they have a plan in place to build another door and wall for separation for storing lost items. They are also going to install an exhaust fan on the soiled side to pull the soiled air outside. During an observation on 03/27/19 at 3:00 AM, there was construction going on in the laundry rooms and an exhaust fan was being installed in the soiled side of the laundry room.",2020-09-01
2267,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2018-06-12,550,D,0,1,ZFV511,"Based on resident interview, family interview, staff interview and record review, the facility failed to maintain residents' dignity by placing them a public area with inappropriate attire. This was found for two (2) of six (6) residents reviewed for the care area of dignity. Resident identifiers: #5 and #26. Facility census 107. Findings included: a) Resident #5 During an interview on 06/05/18 at 10:05 AM, Resident #5 said she went to dinner with her roommate at 6:00 PM on 05/18/18. Resident #5 said after dinner when they returned to their room, the staff would not let them back in the room due to pest control treatment. Resident #5 said staff showered her and her roommate and made them wear a hospital gown afterwards. She further stated the staff made them sit in the lounge until around 11:00 PM while only wearing a hospital gown. Resident #5 was tearful throughout the interview. She stated that her and her roommate are fearful to leave leave the room at the same time now because they do not want what happened on 05/18/18 to happen again. During a phone interview on 05/05/18 at 10:25 AM with a family member of Resident #5, she revealed her mother called her the night of 05/18/18 at almost 11:00 PM. She stated her mother was extremely upset and tearful because they made her wear a hospital gown instead of your own clothes and sit in the lounge this way until 10:00 PM. An incident report filed by this resident's family member was made on 05/21/18. This report was filled out by Social Worker #6. This was not signed by family or the resident. This incident of alleged abuse was not reported to West Virginia Adult Protective Services nor the Office of Health Facility Licensure and Certification until 06/05/18 during this survey. b) Resident #26 During an interview on 06/05/18 at 10:05 AM, Resident # 26 agreed she and her roommate were not allowed back into their room after going the dining room for dinner on 05/18/18. She said it was about 11:00 PM, before they were allowed back let them back in their room. She said that, she was not happy about it and did not appreciate having to set in their lounge in a hospital gown in front of everyone. A report form, Adult Protective Services Mandatory Reporting Form was completed and reported to the West Virginia Department of health and Human Resources, on 06/11/18 at 3:05 PM. by Social Worker #6. During an interview with Administrator on 06/12/18 at 4:00 PM, he said,this incident should have never happened. Someone overreacted over a bug from outside and thought it was a bedbug. I just live over the hill if they would have called me it would have never happened. .",2020-09-01
2268,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2018-06-12,558,D,0,1,ZFV511,"Based on observation, staff interview, and resident interview, it was determined the facility failed to ensure a resident received services with reasonable accommodation of their individual needs. This was found for one (1) of twenty (20) residents randomly observed during the initial pool process of the Long-Term Care Survey Process (LTCSP). Resident #89, who has the ability to use the call light, did not have access to their call light. This practice had the potential to affect an isolated number of residents. Resident identifier: #89. Facility census: 107. Findings included: a) Resident #89 Interview with Resident #89, on 06/05/18 at 10:25 AM, revealed the resident was lying on her bed and complained to this surveyor of having a headache and hurting all over. This surveyor asked the resident if she had told the nurse that she needed something for pain. Resident #89 said, No, not yet. The resident started feeling with her fingers along the left upper side of her mattress and bed railing. When asked what she was looking for, the resident said, I can't find my call light button. This surveyor told the resident, I will get a nurse for you. At 10:33 AM on 06/05/18, this surveyor stepped out into the hall as LPN#38 was walking by. At the request of this surveyor LPN#38 went in to check on Resident #89. This surveyor asked LPN#38 where the call light was. LPN#38 after looking around saw the call light on the floor and picked it up and attached it to bed by clipping it to the mattress. On 06/07/18 at 11:19 AM an interview with the Director of Nurses (DON), revealed she was not aware Resident #89's call light had been found in the floor. The DON stated the resident likes to make up her own bed and things, and probably removed it that morning herself and laid it in the floor. The DON indicated the resident was known to remove the call light, and didn't really use the call light, but would come out to the nurse's station herself to get things. A random observation on 06/12/18 at 11:38 AM revealed Resident #89's call light was again lying on the floor out of the reach of the resident. Resident #89 was observed reaching and feeling for something along the left upper side of her mattress and bed railing. Resident #89 then got up out of bed and started walking toward the door and stopped when she saw this surveyor at the door. This surveyor asked the resident if the surveyor could come in and ask her a few questions. Resident #89 agreed, and when asked where she was going at the time the surveyor came to her room, the resident replied, I needed to find a nurse, so I can get something for a head ache. When asked why the resident does not call for a nurse with her call light button, the resident said, I don't know where it is, I can't find it. A staff Valet (QA#63) was observed outside in the hallway and was requested to come into Resident #89's room to find the residents call light button. Staff Valet (QA#63) came into the room and found the call light button lying on the floor against the wall at the head of the resident's bed. Staff Valet (QA#63) picked the call light button off floor and clipped it on the mattress sheet. Staff Valet (QA#63) agreed the call light was to be in reach of the resident not lying on the floor.",2020-09-01
2269,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2018-06-12,561,E,0,1,ZFV511,"Based on resident interview, medical record review, and staff interview, the facility failed to ensure residents had the right to make choices about aspects of life in the facility significant to the resident. The facility failed to honor the bathing frequency preferences for five (5) of six (6) residents reviewed for the care area of choices and activities of daily living. Resident identifiers: #17, #8, #49, #11, #26. Facility census: 107. Findings included: a) Resident #17 During an interview on 06/05/18 at 7:29 AM, Resident #17 stated she would like to be bathed more often. She stated she received two (2) bed baths a week, but she would like to receive four (4) or five (5) bed baths a week. Resident #17 stated she has requested more frequent baths, but her preference has not been honored. The Nurse Aide (NA) and Activities Supervisor were interviewed on 06/07/18 at 3:02 PM. The NA and Activities Supervisor stated residents are bathed or showered every three (3) days. Upon admission, the residents are assigned to day one, two, or three bathing/showering day. The NA and Activities Supervisor stated she develops the daily bathing/showering schedule based on the bathing/showering day that was assigned to the resident upon admission. If a resident refuses a bath or shower on his or her day, the resident can request the bathing/shower on another day. However, men and women have separate days for showering in the shower room. Review of the bathing task report for 03/14/18 through 06/07/18 revealed Resident #17 did not receive baths every three days. The bathing task report revealed the following information: --03/14/18 - Resident was not bathed --03/15/18 - Resident was not bathed --03/16/18 - Resident was not bathed --03/17/18 - Resident was not bathed --03/18/18 - Resident was bathed --03/19/18 - Resident was not bathed --03/20/18 - Resident was not bathed --03/21/18 - Resident was not bathed --03/22/18 - Resident was not bathed --03/23/18 - Resident was not bathed --03/24/18 - Resident was bathed --03/25/18 - Resident was not bathed --03/26/18 - Resident was not bathed --03/27/18 - Resident was bathed --03/28/18 - Resident was not bathed --03/29/18 - Resident was not bathed --03/30/18 - Resident was bathed --03/31/18 - Resident was not bathed --04/01/18 - Resident was not bathed --04/02/18 - Resident was bathed --04/03/18 - Resident was not bathed --04/04/18 - Resident was not bathed --04/05/18 - Resident was not bathed --04/06/18 - Resident was not bathed --04/07/18 - Resident was not bathed --04/08/18 - Resident was bathed --04/09/18 - Resident was not bathed --04/10/18 - Resident was not bathed --04/11/18 - Resident was bathed --04/12/18 - Resident was not bathed --04/13/18 - Resident was not bathed --04/14/18 - Resident was not bathed --04/15/18 - Resident was not bathed --04/16/18 - Resident was not bathed --04/17/18 - Resident was bathed --04/18/18 - Resident was not bathed --04/19/18 - Resident was not bathed --04/20/18 - Resident refused bathing --04/21/18 - Resident was not bathed --04/22/18 - Resident was not bathed --04/23/18 - Resident was not bathed --04/24/18 - Resident was not bathed --04/25/18 - Resident was not bathed --04/26/18 - Resident was not bathed --04/27/18 - Resident was not bathed --04/28/18 - Resident was not bathed --04/29/18 - Resident was bathed --04/30/18 - Resident was not bathed --05/01/18 - Resident was not bathed --05/02/18 - Resident was not bathed --05/03/18 - Resident was not bathed --05/04/18 - Resident was not bathed --05/05/18 - Resident was bathed --05/06/18 - Resident was not bathed --05/07/18 - Resident was not bathed --05/08/18 - Resident was not bathed --05/09/18 - Resident was not bathed --05/10/18 - Resident was not bathed --05/11/18 - Resident was bathed --05/12/18 - Resident was not bathed --05/13/18 - Resident was not bathed --05/14/18 - Resident refused bathing --05/15/18 - Resident was not bathed --05/16/18 - Resident was not bathed --05/17/18 - Resident was bathed --05/18/18 - Resident was not bathed --05/19/18 - Resident was not bathed --05/20/18 - Resident was bathed --05/21/18 - Resident was not bathed --05/22/18 - Resident was not bathed --05/23/18 - Resident was bathed --05/24/18 - Resident was not bathed --05/25/18 - Resident was not bathed --05/26/18 - Resident was bathed --05/27/18 - Resident was not bathed --05/28/18 - Resident was not bathed --05/29/18 - Resident was not bathed --05/30/18 - Resident was not bathed --05/31/18 - Resident was not bathed --06/01/18 - Resident was bathed --06/02/18 - Resident was not bathed --06/03/18 - Resident was not bathed --06/04/18 - Resident was bathed --06/05/18 - Resident was not bathed --06/06/18 - Resident was not bathed --06/07/18 - Resident was bathed During an interview on 06/07/18 at 3:02 PM, the RNA and Activities Supervisor stated she was not aware Resident #17 would like bathed more than twice a week. The RNA and Activities Supervisor stated residents can be bathed as many times a week as they would like. She was informed Resident #17 was not even bathed every three days, and had an eight (8) day period when the bathing task report stated she did not receive or did not refuse a bath. The RNA and Activities Supervisor stated bathing may have been performed but not documented by the RNA staff. During an interview on 06/11/18 at 11:12 AM, the Director of Nursing (DON) was informed Resident #17 would like bed baths four (4) or five (5) times a week, but review of the medical record revealed the resident had not even received bed baths two (2) times a week. The DON was informed Resident #17 had gone up to eight (8) days without receiving or refusing a bed bath according to documentation on the bathing task report. The DoN had no comment regarding the matter. b) Resident #8 On 06/05/18 at 07:56 AM, an interview with Resident #8 revealed the resident likes his showers in the morning. The resident said he had just moved back from the East wing to the West wing. Resident #8 said he did not like it on the East wing, but they at least had their showers in the morning. When asked if he had told anyone at the facility his preference for morning showers, Resident #8 said he had told the Nurse Aid Supervisor (NA#7) the one who makes the shower schedule, many times that he would like his showers in the morning and told other NAs. When asked what he was told when he requested morning showers, Resident #8 replied NA#7 said he could not have it changed around because it's too big a hassle. Resident #8 said some NAs will go ahead and help him have a shower when he wants it, but others grumble and carry on, it's not worth even asking. An interview with Nursing Aid (NA#43), on 06/07/18 at 10:24 AM, revealed the resident likes his showers in the morning, but he is on the evening shift schedule for every three (3) days. When asked when the resident wants his showers, NA#43 said, He likes them in the morning, but when he moved back to the West wing an evening shift slot was the only one opened. When asked how showers are done at the facility, NA#43 said, (Name of Nurse Aid Supervisor (NA#7)) sets up the shower schedule, we have to follow. NA#43 explained showers are given to a resident every three (3) days, not on any set day, they are simple scheduled every three (3) days. When asked how a NA would know if a resident refused or actually had a shower three (3) days before showing up on the schedule. NA#43 shrugged her shoulders (implying she didn't know) and said, All I know is we just go by the schedule, name (NA Supervisor) takes care of that. NA#43 stated, Resident #8 has come to her and asked to be fitted in on mornings, and NA#43 said, We know that is when he likes his showers, so I try to fit him in mornings when I can, but that is not often. Review of electronic shower records, on 06/07/18 at 02:15 PM, revealed in the electronic record the NAs had the option to either mark 'Yes' or 'No' the resident had a shower. Resident #8's last documented shower was on 06/03/18 at 10:29 PM, four (4) days prior to the day of this review. So far in the month of June, the resident has had two (2) opportunities for a shower and only receive one (1) shower, four (4) days prior to his last shower. The date of the last documented shower prior to 06/03/18 was 05/28/18 at 10:50 AM, six (6) days between showers. The date of the last documented shower prior to 05/28/18 was 05/23/18 at 6:27 PM, five (5) days between showers. The next two (2) recorded showers were three (3) days apart (05/20/18 at 7:26 AM and 05/17/18 at 3:42 PM). The date of the last documented shower prior to 05/17/18 was 05/11/18 at 1:56 PM, six (6) days between showers. The date of the last documented shower prior to 05/11/18 was 05/05/18 at 7:17 AM, six (6) days between showers. In the month of (MONTH) the resident had ten (10) opportunities for a shower and only had six (6) showers. The date of the last documented shower prior to 05/05/18 was 04/29/18 at 5:16 PM, six (6) days between showers. The date of the last documented shower prior to 04/29/18 was 04/26/18, three (3) days apart. The date of last documented shower prior to 04/26/18 was 04/20/18 at 1:49 PM, six (6) days between showers. The next two (2) recorded showers were three (3) days apart (04/17/18 at 3:10 PM and 04/14/18 at 11:23 AM and 10:06 PM). The date of the last documented shower prior to 04/14/18 was 04/08/18 at 5:00 PM, six (6) days between showers. The date of the last documented shower prior to 04/08/18 was 04/01/18 at 10:40 AM, seven (7) days between showers. In the month of April, the resident had ten (10) opportunities for a shower and only had seven (7) showers. On 06/07/18 at 03:02 PM an interview with Nursing Assistant Supervisor (NA#7) revealed NA#7 denied knowing Resident #8's preference was to have showers in the morning, but agreed the resident use to have his showers in the mornings. NA#7 said showers are given to all the residents every three (3) days, either on the men's or the women's shower day, and NA#7 said she makes up the shower schedule. Nursing Assistant Supervisor (NA#7) told the surveyors she thought the residents did get their showers every three (3) days. NA#7 said if there were any lapses of days showing a shower was missing in the record, it was probably just an error in documentation. The NAs must have just forgotten to document. The electronic record allowed NAs the option to either mark 'Yes' or 'No' the resident had a shower. c) Resident #49 On 06/05/18 at 04:21 PM, Resident #49 indicated she did not always get her showers, she said it had been three (3) days since her last shower and she would like one now. When asked if she had told anyone she would like a shower, Resident #49 said, I think they don't want to fool with me, so I won't ask them. Interview with NA#48, on 06/11/18 at 04:00 PM, revealed the resident needs limited assistance with showers. NA#48 was not aware when the resident had her last shower and did not know of a time when the resident refused a shower. NA#48 stated, We go by the shower schedule, that's when we give their showers. Review of electronic shower records, on 06/12/18 at 03:32 PM, revealed in the electronic record the NAs had the option to either mark 'Yes' or 'No' the resident had a shower. Resident #49's last documented shower was on 06/10/18, and the only other shower in (MONTH) was three (3) days prior on 06/07/18. So far in the month of June, the resident had four (4) opportunities for showers and only two (2) showers. The date of the last documented shower prior to 06/07/18 was 05/26/18, twelve (12) days between showers. The date of the last documented shower prior to 05/26/18 was 05/23/18 at 6:27 PM, three (3) days between showers. The date of the last documented shower prior to 05/23/18 was 05/11/18, twelve (12) days between showers. The date of last documented shower prior to 05/11/18 was 05/05/18, six (6) days between showers. In the month of (MONTH) the resident had ten (10) opportunities for a shower and only had four (4) showers. The date of the last documented shower prior to 05/05/18 was 04/30/18, five (5) days between showers. The date of the last documented shower prior to 04/30/18 was 04/17/18, thirteen (13) days between showers. The date of last documented shower prior to 04/17/18 was 04/14/18, three (3) days between showers as scheduled. The date of the last documented shower prior to 04/14/18 was 04/08/18, six (6) days between showers. The date of last documented shower prior to 04/08/18 was 04/02/18, six (6) days between showers. In the month of April, the resident had ten (10) opportunities for a shower and only had five (5) showers. d) Resident #26 During an interview on 06/05/18 at 9:41 AM, Resident #26 said she asked for a shower last week and was told its men's day, and she would have to wait until her next scheduled day to shower, then was told she missed her shower date yesterday. She said they do not like to shower me because I need help. She said the staff that has told her that is Nursing Assistant (NA) #40, and #50 most recently. She said that she was sent to the doctor without being washed up down here (pointing to her genital area) and said she was so embarrassed. She became tearful and said, I stunk up the whole room while they put that thing up my privates. She said it was almost two weeks she had not had a shower when this happened. She said she felt like they were punishing her because one night she told them she did not feel well and was tried and would shower in the morning. She stated that the next morning and days after she was told,It's men's day or it's not your day to shower! She said she has had to call her brothers for help before. During an interview on 06/05/18 at 1:30 PM, with Nursing Assistant/ Supervisor #7 stated that any resident can have a shower whenever they want. She said that the residents are to be showered every three days, and yes, they do have men days and women days. Sometimes they have men or women's days back to back, like men/men/women or women/women/men. During an interview on 06/07/18 at 8:53 AM, Nursing Assistant/Supervisor #7 said that residents can get showers anytime they want except during meal time. During an interview on 06/07/18 at 3:02 PM, Nursing Assistant/Supervisor #7 was asked about shower days. She said the residents have a shower schedule for every three days alternating mens day and womens day sometimes mens day or womens day can be back to back. She could not explain how the shower schedule was made or who determined who gets a shower. Her only answer was,This is the way we have always done it! Review of shower records received 06/7/18 at 2:54 PM, from Assistant Director of Nursing (DON) # 23, for this resident listed days showered/bathed as follows; --04/04/18 at 2:29 PM - showered --04/05/18 at 7:17 AM - not showered --04/05/18 at 11:20 PM - not showered --04/06/18 at 10:32 AM - not showered --04/06/18 at 11:24 PM - not showered --04/07/18 at 7:36 AM - not applicable --04/07/18 at 6:56 PM - not showered --04/08/18 at 10:39 AM - not applicable --04/08/18 at 4:52 PM - not showered --04/09/18 at 9:39 AM - not showered --04/09/18 at 4:40 PM - not showered --04/10/18 at 9:53 AM - showered six days apart --04/10/18 at 11:01 PM - not showered --04/11/18 at 12:53 AM - not showered --04/11/18 at 7:08 PM - not showered --04/12/18 at 11:52 AM - not showered --04/12/18 at 9:52 PM - not applicable --04/13/18 at 10:16 AM - showered three days apart --04/13/18 at 8:41 PM - not showered --04/14/18 at 12:00 PM - not showered --04/14/18 at 3:44 PM - not showered --04/15/18 at 2:29 PM - not showered --04/15/18 at 4:41 PM - not showered --04/16/18 at 2:15 PM - showered three days apart --04/16/18 at 3:34 PM - not showered --04/17/18 at10:28 AM - not showered --04/17/18 at 3:52 PM - not showered --04/18/18 at 2:29 PM - not showered --04/18/18 at 6:42 PM - not showered --04/19/18 at 1:36 PM - showered three days apart --04/19/18 at 8:55 PM - not applicable --04/20/18 at 11:00 AM - not showered --04/20/18 at 3:50 PM - not showered --04/21/18 at 2:12 PM - not showered --04/21/18 at 4:29 PM - not showered --04/22/18 at 2:29 PM - not showered --04/22/18 at 4:38 PM - not showered --04/23/18 at 7:16 AM - not applicable --04/23/18 at 5:06 PM - not showered --04/24/18 at 9:12 AM - not showered --04/24/18 at 6:47 PM - not showered --04/25/18 at 10:44 AM - not showered --04/25/18 at 3:28 PM - not showered --04/26/18 at 10:46 AM - not showered --04/26/18 at 7:39 PM - not applicable --04/27/18 at 2:29 PM - not showered --04/27/18 at 3:52 PM - not showered --04/28/18 at 2:29 PM - not showered --04/28/18 at 9:15 PM - not showered --04/29/18 at 12:14 PM - not showered --04/29/18 at 5:03 PM - not showered --04/30/18 at 2:29 PM - resident not available (at doctor's appointment) --04/30/18 at 6:30 PM - not showered --05/01/18 at 2:29 PM - showered 12 days apart Nursing note dated 02/19/18 at 8:53 PM note staff offered to give resident shower d/t her refusal on previous day states no I'm tired ill just wait until tomorrow explained to resident that the next day would not be her scheduled day and she may have to wait until weds states that's fine I'll just wash off at the sink thank you Review of nursing notes dated on 02/20/18 at 8:54 AM the note revealed (typed as written): --resident to desk states, I've been waiting forever for a shower explained to this resident the cna's (nurse aides) would attempt to get her in shower sometime today d/t several residents were already receiving showers at time of request. resident states, well I'm sick of never getting a shower reminded resident that she had refused X3 when 3 different cna's attempted to take to shower previous evening resident then said well I'll just go wait let me know when i can get one. Nursing noted dated 04/30/18 at 4:34 PM revealed resident returned to facility from (local hospital after having a colonoscopy) via gurney. e) Resident #11 On 06/05/18 at 9:36 a.m., the resident expressed concern she had not received a shower in a long time. According to the resident she was upset over this practice, she wanted a shower a least every three (3) days. Review of the electronic medical record documentation, regarding resident bathing with Employee #7, the registered nursing assistant/activities supervisor, at 3:14 p.m. on 06/07/18, found the following information: The electronic medical record required nursing assistants to answer the question, Was resident bathed/showered this shift? Staff could respond with yes, no, not applicable or resident refused. E #7 said it is the facility expectation is all residents are offered a shower every three (3) days. Residents are allowed to refuse the activity. Documentation of the bathing activity from 05/01/18 to 06/06/18 found the following dates when the documentation did not support bathing activity every three (3) days: Resident #11 was bathed on 05/21/18 the next bathing activity occurred on 05/27/18- a period of five (5) days between bathing activity. Bathing was provided on 05/27/18, the next bathing activity occurred on 06/05/18 - a period of nine (9) days between bathing. The bathing activity was recorded in the electronic medical record as occurring at 10:02 p.m. on 06/05/18. Therefore, when the resident stated at 9:36 a.m. on 06/05/18 she had not received a shower in a long time, she had not received a shower for the past nine (9) days. E #7 confirmed the staff did not document the resident refused bathing during these time periods. At 10:59 a.m. on 06/11/18, the above information was discussed with the Director of Nursing (DON). The DON said, She (referring to the resident) would normally tell me if she didn't get a shower but she didn't tell me. At the close of the survey at 5:30 p.m. on 06/12/18, no further information was provided to validate the resident received her bathing activity every three (3) days per her preference and facility practice.",2020-09-01
2270,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2018-06-12,584,E,0,1,ZFV511,"Based on resident interview, staff interview and policy review, the facility failed to provide a reasonable protection of the residents' property from loss or theft. This was true for four (4) out of seven (7) residents reviewed for the care area of personal property. For Resident identifiers: #5, #44, #26 and #8. Facility census 107. Findings included: a) Review of Facility policy Resident Personal Property Dated (MONTH) 24, (YEAR) required the following: --The resident and/or family representative will be notified of the loss or breakage of personal items. --Any loss or breakage of a resident's personal item will be properly documented on a complaint form by the social worker or designee and then referred to the facility administrator. --The lost or broken items will be investigated. --If the investigation identifies misappropriation of patient property, refer to the abuse and neglect policy. --Results of the investigation will be given to the resident or representative and documented. b) Resident #44 During an interview on 06/05/18 at 8:53 AM, Resident #44 said she had clothes, a Bible and a green clock that sings Christmas songs missing. States she told Nurse Aide/ Nurse Aide Supervisor (NAS) #7 but nothing was replaced. During an interview on 06/07/18 at 8:30 AM, NAS #7 said they replace her clock but do not know about the Bible. She was asked if a report was made, she replied, no. Upon record review no reports about these complaints were found in the record or other location. During an interview on 06/07/18 at 2:44 PM, NAS #7 she said that the facility is always buying things for this resident and all the residents. She provided the facility policy for resident personal property. She also gave various papers with copies of Walmart receipts with items circled with many of the same items on the list and some hand-written list for mileage reimbursements nothing to do with any of the missing or replacement of items. She could not provide any proof of the items Resident # 44 reported missing being found or replaced. c) Resident #5 During an interview on 06/05/18 at 9:58 AM, Resident #5 said staff go through her stuff and she had had things missing. Tearful she said she cannot leave her room because thing come up missing. She said,After the incident where the staff bombed (pest control) my room and would not let me and her (her roommate) back in their room. More stuff has come up missing. She stated her daughter does her laundry, but the staff still take all her clothes to the laundry and ruined them. Things that are missing are bras, snack cakes, pop and a small amount of money (a dollar or some change). During a phone interview with the Resident's daughter on 06/05/18 at 10:25 she said that did have 29 outfits to start with and she now has only 19 remaining in her possession. During an interview on 06/07/18 at 8:34 AM, NAS #7 said, I don't know anything about, the missing clothes. However, she provided a Walmart receipt for this resident. She denied any reports being made or investigations being done. During an interview on 06/07/18 at 10:29 AM, Social Worker (SW) #6 stated she was not aware of the missing items nor the fact the resident was afraid to leave her room because of ongoing issues with missing property. She said that NAS#7 said they could get her a lock for her cabinet. d) Resident #26 During an interview on 06/05/18 at 10:29 AM, Resident #26 said she has had many clothes missing, cookies, snack cake, pop and perfume. She stated that she had reported to NAS #7 and had to hide her stuff or not leave her room. During an interview on 06/07/18 at 8:37 AM, NAS #7 said that she always replaced the items, but did not have any documentation to show what and when items were replaced. During an interview on 06/07/18 at 10:21 AM, SW #6 said she has never been told about this resident missing anything. e) Resident #8 Interview with Resident #8, on 06/05/18 at 07:53 AM, revealed the resident had lost many personal items at different times, more than he could count. Resident #8 said he had been a resident the last two (2) years and has had many things missing. When asked if there was anything recent, the resident said about four (4) months ago a T shirt with a pig on it that he really liked. When asked what the facility said they would do about it, the resident replied, Name of NA/Activities Supervisor (NA#7) said they would see what they could do, but did not do anything. Resident #8 said, If you got any jewlery they'll get it. I don't leave anything lying around. On 06/07/18 at 08:55 AM, during an interview with NA/Activities Supervisor NA#7 was asked what was done about Resident #8's missing shirt. NA#7 replied, I got all his receipts. Later NA#7 brought this surveyor copies of nine (9) different receipts, with various dates, from Wal-mart listing many different items. Some of the items were circled. NA#7 could not provide a record of what all Resident #8 had actually missing to compare the receipts to. NA#7 agreed that she would have to develop a different way to track missing items and their replacement. NA#7 acknowledged review of documentation brought to this surveyor could not distinguish whether Resident #8's had all of his missing items replaced.",2020-09-01
2271,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2018-06-12,600,H,0,1,ZFV511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record, Incident/Accident reports, Complaints/Grievances and Reportable reports, staff interview, resident interview and review of the facility's abuse policy, the facility failed to ensure each resident was free from abuse and neglect. Additionally, the facility failed to not use verbal, mental, sexual or physical abuse, or involuntary seclusion. This deficient practice caused actual harm for Residents #89, #99, #26 and #5. This deficient practice had the potential to affect more than an isolated number. Resident identifiers: #89, #99, #26, #11, #71, #5, #44, #58, #4, #212, #114. Facility census: 107. Findings included: a) Resident #89 1) Review of Resident #89's medical records found an annual Minimum Data Set (MDS) with an Assessment reference date (ARD) of 11/07/17. This MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 for severe cognitive impairment. Resident # 89's [DIAGNOSES REDACTED]. Severe confusion was noted with poor safety awareness with a history of falls. Resident #89 required the physical assistance of one person with bathing/showering. Resident #89 was noted as always continent of bowel and bladder functions. Requiring only supervision with most Activities of Daily living except bathing and personal hygiene. 2) A review of the Incident/Accident reports found on 02/01/18 at 10:20 AM found an incident occurred in the shower room. The incident description was as follows: Called to shower room per staff. Resident sitting in floor in shower room. Resident noted to have a complaint of pain in left wrist. Left wrist noted to be swollen at this time. Resident has no other complaints of pain. No redness or bruising noted at this time. Resident was unable to give description states, My wrist is really hurting me. Resident noted to be holding left wrist at this time. Resident was transferred to nearby hospital and was diagnosed with [REDACTED]. A review of statements by the two (2) nurse aides (NA) present in the shower room found: --Statement by Employee #56, NA read: I was showering (Resident #89's name) with another staff member in the shower room. As I turned to get a piece of clothing the resident got up and tried to walk by herself and lost her footing and fall the other staff member (Employee #43, NA) tried to catch her but wasn't quick enough then got (Employee #32, licensed practical nurse (LPN) name. --Statement by Employee #43, NA read: I was assisting another staff member in showering resident (Resident #89). As the other staff member turned to get a piece of the resident's clothing. Resident got up unassisted. She lost her footing. I tried to catch her but I was too late. 3) Review of the significant change MDS with an ARD of 05/09/18 found the resident has had a decline in her activities of daily living (ADL) and has more episodes of incontinence. Resident remains alert to person only and continues to have poor safety awareness secondary to impaired cognitive status. This indicates following the incident on 02/01/18 resulting in a fractured left wrist, Resident #89 has experienced a decline in her ADL status and incontinence status. 4) On 02/02/18 at 11:00 AM an in-service was provided on Proper showering techniques the following was included, Maintain a face-to-face contact when possible, stay with resident during the entire process . do not leave residents alone while bathing or showering . This indicates actual harm for Resident #89 due to leaving the resident unsupervised and out of reach while in the shower resulting in a fall acquired fracture and pain. b) Resident #99 1) Review of the reportable allegation of abuse found a report for Resident #99, dated 05/23/18 at 1:34 AM, this report read Resident told reporter (Employee #6, Social Worker (SW) that she was trying to get out the door to smoke. She tried to get a lighter out of the alleged perpetrator's pocket. While trying to get the resident back into the building, it was alleged that (Employee #59, licensed practical nurse (LPN) grabbed Resident #99's right hand and squeezed her fingers hard causing pain. Resident #99 stated, It hurt real bad. I thought she had broken it. Review of statements found: --Statement by the alleged perpetrator, Employee #59, LPN read: On 05/23/18 at 11:34 AM, Resident #99 was trying to exit through the back door, as I was trying to redirect the resident. The resident was moving wheelchair back into facility the resident grabbed the door frame. I slid my hand under her wrist to guide it backwards. The resident started putting her hand in my pockets, when I asked her not to. At which time resident became agitated and stated, She was going out and we couldn't stop her. then she turned her wheelchair and propelled her self-down the hallway muttering and cursing. --Statement by the nurse whom examined the resident, Employee #23, RN read: This nurse was on East wing, approached by SW and asked to assess (Resident #99's) hand. Resident sitting in her room in her wheelchair at bedside with remote in hand. This nurse asked her if something occurred, she stated, Yes, I don't remember if it was yesterday or today. I was going outside to smoke. I opened the door, I know all the codes. Somebody grabbed my chair, it jerked me backwards. I couldn't go forward or backwards. I saw the girl's lighter in her pocket and I grabbed it. She grabbed my hand and squeezed it real hard. It hurt bad. I thought she broke it. I continued to assess the resident's right hand, this is the hand that was squeezed . 2) Only statements obtained was the perpetrator, Employee #59, LPN and Resident #99. Employee #23, registered nurse (RN) provided a statement with her assessment of Resident 99's injuries (she did not observe the incident). 3) Interview with Resident #99, on 06/05/18 at 9:15 AM, she stated, The staff punishes me with not letting me smoke with the other residents due to I feed the cats my leftover food and cat food that I have bought. They say all kinds of stuff to me, they mock me and they take the food I have for the cats and throws it in the trash can in front of me and says, Ha,Ha. They grab my wheelchair and prevent me from moving and jerks my chair backwards at times. Employee #59 squeezed my hand/fingers one time so hard I thought she broke it. The resident appeared distraught and upset as she recalled these incidents. This deficient practice has caused Resident #99 actual psychosocial and physical harm which caused mental anguish, pain, intimidation, punishment, and humiliation. c) Resident #11 1) Review of Complaint/Concern log found a complaint for Resident #11 dated 03/14/18 and made by the resident's family. The concern stated, (DON's name) received a call from (Name of resident's family) on 03/14/18. Also, another family member was also on the call. The family stated, I want to report abuse. Nurse Aide (NA) #46, is pulling out resident's hair. The family member stated, I have reported this to Employee #23, RN and nothing is been done. The family goes on to say they do not want NA #46 taking care of her as they feel mistreatment by NA #46 is a retaliation due to some criminal activity by residents and NA #46's family. A review of the statements found: --Statement by Director of Nursing (DON) #18, NA #7 and Registered Nurse (RN) dated at 2:00 PM on 03/14/18, statement read: Employee #23, NA #7 and myself (DON) went to the residents room. I asked her if she was happy here and she stated, No, I want to go to[NAME]on. I asked her if everyone is good to her and she stated, They take my stuff. I asked her if anyone has done anything mean to her and she stated, No. I asked her if anyone had smacked her or hit her she stated, No. I asked her if NA #7, RN #23 or myself (DON) had ever pulled her hair and she stated, No. She denied anyone being mean to her and stated they take care of her. --Statement by Employee #46, NA, the alleged perpetrator read: I was putting the resident (Resident #11) to bed after the last smoke break. The resident became combative and I asked the nurse (No name mentioned) to assist me with the resident. She continued hitting and scratching me. We got her in bed and I was removing her jewelry and the necklace pulled her hair. I told her, I was sorry and she said, She was fine and told me to put her stuff on the table. d) Resident #71 1) A review of the Complaint log found a complaint dated 03/28/18. This complaint was from Resident #71 and was made to the DON. This complaint read: (Resident's name) made a complaint that the staff got her up at 4 am to take a shower. 2) No statements or investigation could be found. After this surveyors intervention it was determined by the staff this was an allegation of neglect/abuse. e) Resident #44 Review of the grievance/concern forms for the last year found three (3) concern/allegations: 1) Allegation #1: On 06/08/17, Resident #44 reported that Licensed Practical Nurse (LPN) #36 did not give her medication to her. The resident reported this to RN #123, who informed the DON. Social Worker (SW) #124 and DON spoke with the resident separately concerning her allegation. Resident denies the allegation of abuse, neglect or anyone treating her in a mean manner. She stated she does not like her nurse because she crushes her medicine. On 06/22/17, resident is no longer receiving medication crushed. Review of the statements found: I explained that I could not give a medication without an order from the physician and again I explained I would contact the physician regarding residents request. I attempted to explain the parameters for Tylenol toxicity due to the resident currently had an order for [REDACTED]. At this time, RN #123 states well you are well within your limits and what could Tylenol hurt? This writer attempted to let Rn #123 know of resident's drug seeking behaviors but that again one of us would contact the physician and let her know the residents request. Statement by Employee #16, LPN on 06/01/17 at 17:40 (5:40 pm): A resident went up to (Employee #123's name) and told her she had a temperature of 99 degrees. The RN came out and told the nurse to give her two (2) Tylenol. Staff attempted to explain to the RN we could not give medication without a physician's orders [REDACTED].#116 two (2) Tylenol. Resident stated she had a temperature of 99 degrees. Staff again attempted that we could not give it. This nurse took RN into the office and attempted to give some of the resident's history with being told I was just an LPN and that she had been a nurse for [AGE] years. Rn became loud to the point that it was almost a scream cutting this nurse off. Statement by Employee #36, LPN on 06/06/17 at approximately 15:10 (3:10 pm) While sitting at nurse's station attempting to complete paperwork to send a resident to hospital. RN #123 is noted to approach the nurse's station and state, I need drugs this writer informed her that I would be with her in just a minute as I was on the telephone attempting to transfer a resident to the hospital. RN #123 states, I wasn't speaking to you, I was speaking to Employee #57, nurse assistant (NA). This writer explained if you are referring to Resident #214's antibiotic then I am his nurse and Employee #57, NA cannot help you. Then Rn #123 stated, I apparently, I didn't make myself clear I was speaking to Employee #57, N[NAME] Again, this writer explained I was the resident's nurse and would get the medication for her in a minute that I am in the process of sending someone to the hospital. RN #123 stated, Obviously, you don't seem to understand that I am not speaking to you. At this time, this writer went into the med room and got the said antibiotic and handed it to the RN #123. RN #123 walks off. Statement by Employee #36, LPN on 06/08/17 at approximately 18:45 (6:45 pm) Front door alarm sounds and this writer proceeds up to the front to check for safety and reset the alarm. I proceeded out to the parking lot to be sure that no residents were in the parking lot unattended. For further safety, this writer walked around building to be sure the parking lot and surrounding areas were clear. This writer then proceeded to the west wing to check with nursing staff to be sure all residents were accounted for. Upon entering front hall of the east wing (Employee #123, RN name) was noted to be standing at the nurses station with the Medication Administration Report (MAR) for the A section opened. This writer enters the nurses station to begin charting on the computer when Employee #123, RN states, You did not give (Resident #44' name) her meds today. At this time this writer states, yes I did. Employee #123, RN then states, Well, I don't think you did. She told me you didn't. I explained to the RN that the resident has hoarding behaviors, refusal of medications and false accusations. The RN then states, Well if she says you didn't give the medication, as far as I concerned you didn't. RN proceeds to state, There are no initials in the box (referring to the MAR). Then asked, Is 0900 9am or pm. At this time, I stated 0900 is 9am and I have been checking my MAR to be sure all of my finger sticks and etc. has been documented. RN then states, Well, apparently you did not learn anything in nursing school, you are to sign medication out when you give them, therefore, as far as I am concerned you did not give her medication and that is abuse. At no time did the RN allow me to see which area of MAR that she was referring to and nor did she know the resident had been found with a [MEDICATION NAME] (pain medication) in her bra. While attempting to explain this resident's behavior the RN became loud and she pointed her finger in this writers face and saying, Where were you when I was looking for you. I explained I was assessing the situation with the door alarm going off and being sure there was no elopement, while she sat in the office not responding. She (RN) continued to point finger in this writer's face. This writer states, please get your finger out of my face. RN states, you need to get in the office to continue this conversation. This writer informed the RN , I will not go to a private area to hold a conversation with you alone. You are pointing your finger in my face and approached me here in front of my peers and other residents. So, I will not go to a private area with you if you want to speak to me I will do it in front of the DON only. At this time, the RN looks to her right where several staff as well as residents in the hallway. The RN then states, (Employee #57, NA name) go to the office. At this time this writer explained that the NA was a union representative but as a union employee I did not wish to have her present to speak with the RN without the DON in the building due to her aggressive tone with me. RN states, Well, we will see about this I am calling the DON. At no time during this shift did this RN look at any other MAR located on the east wing or any other resident's MAR regarding medications or administration. But the RN stated, Well she is my family and I will take care of this. Statement by Employee #125, SW read, On 06/09/17, I spoke with resident, (Resident #44's Name), regarding allegations a nurse made that the resident was not getting her medications. (Resident #44's name) came to my office in private and I asked her if any nurse failed to give her medications to her. The resident stated, No, I get my medication but she makes me take them crushed and I don't like that. I then looked in the resident's chart to verify that the resident had an physician's orders [REDACTED]. There was a fact an order stating that the resident was to receive crushed meds. I explained this to the resident and she stated her understanding. Statement by Employee #60. LPN read, On 06/11/17, I worked the A hallway on the west wing and (Employee #39, LPN name) worked B hallway. She came to me with a [MEDICATION NAME] (pain medication) in a cup and asked me to waste it with her. She stated she had popped it out in error when pulling a residents medicine, Medication was wasted. We counted at the end of shift and a [MEDICATION NAME](pain med) was signed out by Employee #39 for 06/11/17 at 9 pm and count was correct. 2) Allegation #2: Resident #44 reported an allegation of neglect on 06/12/17 to RN #123. RN #123 reported teh allgeation to the Nursing Home Administrator and DON. The allegation made by the resident was not given her medication by LPN #123. LPN #123 went to the resident's room to confront the resident by reportedly saying, Since you told on me now your medication will be crushed and I will give them to you in the hallway. Employee #124, social worker (SW) talked with resident regarding the allegations and resident denies the allegation. The resident continues to deny any issues with staff being mean to her. She continues to be upset about her medications being crushed. A review of the statements found: --Statement by Employee #44, RN, made on 06/12/17 at 5:35 p.m.: While doing skin assessments, patient in room [ROOM NUMBER]- (Resident #112, Name) called me into her room. She asked me if I was a nurse and I told her yes. Resident stated she did not receive her 9 pm meds last night. I asked her did she know what med, she stated little blue pill (pain pill- [MEDICATION NAME]). I told her I would check the MAR (Medication Administration Record), it may have been not available. I checked the MAR and the medication ([MEDICATION NAME]) had been signed out with the initials of (Employee #39, LPN). I went back into Resident #112's room with Employee #125, Graduate Nurse (GN). What month is it? she stated, June. I asked the year, she stated, (YEAR). I asked her who was the President, she said, Trump. I asked her if she was mistaken, she said, No, I check my pills, my pain pill is the little blue pill and it wasn't there. And I asked the nurse (Employee #39) about it and she told she didn't have it and that they would give it at 12:00 a.m. She went on to tell me several nurses about it and nobody came to see her. --Statement by Employee #49, NA read: On (MONTH) 12, (YEAR) (time ineligible) I was putting (Name of Resident #76) in bed. The wife of Resident #76 was in the room. Employee #124, RN came in the room to do an assessment on the resident. The RN #124 started talking to the resident's wife about an incident that happened on east hallway. She told the wife it involved Resident #44 and Employee #36, LPN. She said she was in the bathroom and heard everything between Resident #44 and LPN #36. She told the wife she had took it to the Administrator and the DON. She told the wife she had screen shot all the nurses whom had been notified. She said they were that the facility was trying to get rid of her and that she reported it to the state. On (MONTH) 20, (YEAR) the wife of Resident #76 was told by RN #124 this morning she had received her letter from the state and they were investigated. --Statement by Employee #41, NA, written on 06/12/17 read: I witnessed a resident come up to the RN and asked about her medicine, The RN came up to the nurse's station and asked where the nurse was at. The RN started looking through the medicine book and when the LPN came back to the nurse's station the RN asked the LPN about the resident's medicine and the MAR book. The RN was telling the LPN she must have not learned anything or she would have signed the book when she gave the resident meds. RN points at LPN and asked her to come to the office. LPN asked the RN to stop pointing her finger in her face. The RN said I'm not pointing in your face. --Statement by Employee #125, SW, written on 06/12/17 read: On 06/12/17, SW spoke with (Resident #44's name), regarding allegations the LPN #36 had not gave her medications and that she came into her room and stated, Since you told on me now your meds will be crushed and I will give it to you in the hall. Resident #44 denies that this was said and also says, Nobody has been mean to me here but I don't like that nurse (LPN #36) because she crushes my meds. --Statement by Employee #127, NA written on 06/12/17 read; I witnessed Resident #44 go into the DON's office and told RN #124 she had not had any of her medicine all day. The RN looked at the MAR and the book had holes in it where the LPN had not signed the MAR. The LPN assured the RN she had gave the meds but had not signed the MAR. The RN's and the LPN's voices kept getting louder. 3) Allegation #3: A review of the concern/grievance log found a statement on 06/20/17 at approximately 9:00 AM, NA #58 entered Resident #44's room to find her roommate some clothes, this resident had her roommates pants on. I came out and got my nurse (LPN #36) to assist me. The housekeeper and I was standing in the closet doorway and Resident #44 exited the bathroom holding the clothes. The resident threw the pants and hit LPN #36 in the side of head and then openly smacked her across the face knocking her glasses off. I attempted to get the resident away from the nurse and calm her down. The resident started yelling at the nurse stating, I am going to have your job [***] . I dare you to hit me queer. --Statement by Employee #36, LPN dated 06/20/17 at 9:15 am read: Upon entering Resident #44's room I found the resident had her roommates pants on. This writer, NA and Housekeeper were standing in the doorway of this resident's room when she exited the bathroom striking this nurse in left side of face multiple times screaming, (RN #124) and I are going to have your job [***] . I dare you to hit me I'm calling RN #124 and she will beat your face in. This writer exited the room and notified the supervisor of this resident's behaviors and notified the physician with new orders to administer [MEDICATION NAME] 20 milligrams (mg) intramuscularly (IM) now for agitation. Power of attorney (POA) notified and made aware of residents room change from east to west wing. --Statement by Employee #125, SW read: On 06/20/17, I talked with Resident #44, to discuss her recent behaviors against LPN #36. I asked (Resident #44) why she hit LPN#36 and the resident stated the nurse was discrimating against her. I then asked her why she felt LPN #36 was discriminating against her and she stated, She crushes my medicine and RN #124 told me it was discrimation. I then asked the resident why she called the LPN #36 a queer. She at first denied calling her a queer but later she said, RN #124 told me that she was married to a girl so what would you call her. I told the resident that she could not act that way toward a staff member regardless of her personal opinion. The resident states understanding. f) Residents in room [ROOM NUMBER] on 06/19/17 1) A review of grievance/concern book found an incident, in which, occurred between RN #124 and Employee NA #54 on 06/19/17 at 9:30 PM. Review of the statements found: --Statement by Employee #124, RN read, On 06/19/17 at around 9:30 pm I went to find who had Resident #117 to do a skin assessment. The NAs stated that NA #54 had Resident #117. I went into room [ROOM NUMBER]and pecked on the door, when I entered the room I said, Good I need to do (Resident #118's skin assessment and you have her undressed. NA #54 said, Why you want to look at her ass. I asked him what he meant by that and he said, I don't have time for this. I told him I needed him to help me turn Resident #117 on her side for a skin assessment that I had already did everything but her buttock and back. NA #54 stated, I have more patients to do and you treat NAs and nurses like were dirt under her feet. I told him that wasn't true and I hadn't even talked to him before, that I was told to get help turning the patients and he kept saying you never asked. I asked again for help and he refused. I told him I was going to write him up for insubordination and he stated, I am getting a union representative. As I came down the hall I stated, I hate it when people are smart asses. Statement by Employee #54, NA read: I was on west wing and was in room [ROOM NUMBER] assisting the residents in getting ready for bed, when RN #124 came into the room and told me that I was to come to room [ROOM NUMBER]. I asked her to give me a minute, she then told me that she needed me to do it now. I told her she needed to give me a minute. I asked her if she needed to look at their butt. She then told me I was getting wrote up for insubordination. I never refused to help. I told her to give me a minute. Then she yelled at me and called me a smartass. She stated she was the RN and that meant I would do as I am told and not question her. She pulled her name badge at my face and said that is what this means. g) Resident #58 1) A review of the Complaint/Grievance book found a concern by Resident #58. This allegation was reported to Employee #125, SW on 01/23/18. Concern: Resident reports that she doesn't know how to take the Employee #43, NA on evening shift. NA sometimes. She takes good care of me but she likes to joke and sometimes doesn't know how to take her. She makes me anxious. Interventions: NA #43 received a written warning. The resident no longer has the NA as her caregiver. 2) No further statements, investigation or intervention could be located. h) Resident #4 1) A review of the complaint/grievance book found a concern by Resident #4. This allegation was reported to SW #6 on 06/01/18. Concerns noted by Resident #4's family read: Still not getting coffee at all meals. Staff were mocking the resident Help at the west wing nurses' station. One NA would not give the NA caring for Resident #4 the proper size of diapers. Wednesday, pm shift. The resident was lying angled in her bed. She couldn't get to her tray to eat. She had a bowl of peaches in her bed with her. She needs pulled up to the tray to eat her meals. Residents name is not over her bed it is a different residents' name. Interventions: Coffee is being served at all meals. Diaper issue is resolved. Resident will eat in day lounge (sitting upward). 2) No further statements could be located. i) Complaint made by the Ombudsman 1) A review of the complaint/grievance book found a concern by the Ombudsman. This allegation was reported to SW #6 on 05/15/18. Concern: I had more complaints of staff being rude to residents. One employee (NA) was huffing and puffing and complaining because they were short staffed and everyone was acting crazy. After the visitor reported this a resident spoke up and reported a nurse who is mean and hateful and this nurse had to shut up and quit talking so much. The NA said that is her personality. There is one employee that is hateful as the devil; when one resident asked for a drink and another asked if there was church tonight; she yelled and was hateful to both residents. Please address this issue with your staff. 2) This surveyor was provided a copy of an in-service for Ethical behavior and Unethical behavior conducted on 05/16/18 by the Administrator. 3) No further statements could be located. j) Resident #114 1) Review of Resident #114's medical records found the resident was admitted on [DATE]. Care Plan initiated; Resident is a 53yr. old female-Diagnosis: [REDACTED]. Staff supervises meals, assists as needed. She is noted to take food from other resident's trays. Easily agitated. Diet Regular NAS with lidded cups for safety. Weight 102# --below IBW range (123#-149#) She feeds herself meals--often uses her fingers to eat --likes sweets and snack foods. No teeth or dentures. 2) Progress notes found the following incident/altercations involving resident-to-resident: --10/18/2017 at 08:28 - Resident noted to be up walking around day lounge throwing food on the floor and taking food from other resident's trays. --10/19/2017 at 18:00 - Resident up and ambulating in day lounge throwing her shoes across room pushing furniture against resident's wheelchairs. staff sits down with resident to assist with meal resident then gets up and proceeds to remove food from her brother's tray. when attempting to redirect resident begins hitting self in head and slamming fists on wall, offered activities, fluids and snacks with staff to monitor for safety. --11/6/2017 at 18:00 - Another resident was calling out to resident and calling her names. Resident became agitated and grabbed other resident's hair and pulled hard. Residents were separated by staff. Vital signs unable to be obtained due to resident was agitated. --11/9/2017 at 21:46 - Late Entry: Note: resident has been noted to be up wandering in other resident's rooms, taking food and drinks off resident's dinner trays this shift requiring redirection numerous times. --11/27/2017 at 07:59 - Resident up ambulating in day lounge removing food from other resident's trays requiring redirection numerous times. resident becomes agitated and begins hitting self in head. attempts to take resident to room for self-soothing. --12/7/2017 at 13:20 - Resident in day lounge at this time alert and nonverbal skin clean dry warm to touch resident noted to hit her head on the walls and glass numerous times this shift , staff makes attempts to redirect this resident , with no positive results noted , this resident noted to be grabbing other residents chairs in the day lounge and halls x 4 this shift staff attempts to redirect this resident to the day lounge resident placed in chair at which time resident proceeds to kick and hit staff numerous times along with attempting to hit her head on tables and chairs in the day lounge , staff remains with resident at this time. --12/7/2017 at 17:40 - Resident continues to be aggressive to staff along with continues to hit her head on the walls and windows, with each attempt to redirect this resident from getting upset and pushing another resident's wheelchair. --12/12/2017 at 09:35- Resident is noted to be standing at the nurse's station grabbing other resident w/c as they pass x 1 this shift along with getting notably agitated x 1 at nurse station then enters the day lounge door and began to push and shake another residents merri walker resident assisted to room via staff now to self-soothing. --2/14/2018 at 15:21 - Resident was agitated and shoving tray tables and tables in dining area. when this nurse enters dining area to calm her down another resident stated that you smashed my hand remover other resident near nurse's station for further evaluations. --2/27/2018 at 10:30 - RNA states that Resident was in DL and ran over and grabbed another female resident by the hair and got ahold of her left breast. No injuries were noted to either resident. The residents were separated. --3/16/2018 at 16:40 - Nurse called to day lounge this resident grabbed another resident by arm and struck him on his chest. staff separated residents and redirected this resident verbally and assisted to sit on couch to watch the television. vital signs refused now. --3/26/2018 at 15:56 - Reported via staff that resident has been noted to get in bed with roommate now, resident removed from roommate's bed. Will continue to monitor resident --3/26/2018 at 16:30 - Resident has been noted to run up and grab another resident's mobile device now. Resident's separated now. Both residents assessed, no injuries to either resident. Will continue to monitor. --3/26/2018 at 17:00 - Called to resident's room via staff, resident is lying in roommate's bed, with roommate in the floor bedside bed. Tries to re-direct resident to correct bed now. Resident cooperated with success of redirection. --3/26/2018 at 17:30 - Reported via staff that resident went up to another resident that was in a w/c, grabbed his arms and put her head down as if she was (TRUNCATED)",2020-09-01
2272,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2018-06-12,609,H,0,1,ZFV511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record, Incident/Accident reports, Complaints/Grievances and Reportable reports, staff interview, resident interview and review of the facility's abuse policy, the facility failed to ensure each allegation of alleged or acutal abuse and neglect to the State Survey Agency and Adult Protective Services. This deficient practice caused actual harm for Residents #89, #99, #26 and #5. This deficient practice had the potential to affect more than an isolated number. Resident identifiers: #89, #99, #26, #11, #71, #5, #44, #58, #4, #212, #114. Facility census: 107. Findings included: a) Resident #89 1) Review of Resident #89's medical records found an annual Minimum Data Set (MDS) with an Assessment reference date (ARD) of 11/07/18. This MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 for severe cognitive impairment. Resident # 89's [DIAGNOSES REDACTED]. Severe confusion was noted with poor safety awareness with a history of falls. Resident #89 required the physical assistance of one person with bathing/showering. Resident #89 was noted as always continent of bowel and bladder functions. Requiring only supervision with most Activities of Daily living except bathing and personal hygiene. 2) A review of the Incident/Accident reports found on 02/01/18 at 10:20 AM found an incident occurred in the shower room. The incident description was as follows: Called to shower room per staff. Resident sitting in floor in shower room. Resident noted to have a complaint of pain in left wrist. Left wrist noted to be swollen at this time. Resident has no other complaints of pain. No redness or bruising noted at this time. Resident was unable to give description states, My wrist is really hurting me. Resident noted to be holding left wrist at this time. Resident was transferred to nearby hospital and was diagnosed with [REDACTED]. A review of statements by the two (2) nurse aides (NA) present in the shower room found: --Statement by Employee #56, NA read: I was showering (Resident #89's name) with another staff member in the shower room. As I turned to get a piece of clothing the resident got up and tried to walk by herself and lost her footing and fall the other staff member (Employee #43, NA) tried to catch her but wasn't quick enough then got (Employee #32, licensed practical nurse (LPN) name. --Statement by Employee #43, NA read: I was assisting another staff member in showering resident (Resident #89). As the other staff member turned to get a piece of the resident's clothing. Resident got up unassisted. She lost her footing. I tried to catch her but I was too late. 3) Review of the significant change MDS with an ARD of 05/09/18 found the resident has had a decline in her activities of daily living (ADL) and has more episodes of incontinence. Resident remains alert to person only and continues to have poor safety awareness secondary to impaired cognitive status. This indicates following the incident on 02/01/18 resulting in a fractured left wrist, Resident #89 has experienced a decline in her ADL status and incontinence status. 4) On 02/02/18 at 11:00 AM an in-service was provided on Proper showering techniques the following was included, Maintain a face-to-face contact when possible, stay with resident during the entire process . do not leave residents alone while bathing or showering . 5) This incident was not reported as potential neglect until 06/12/18 (after surveyor intervention). The Social Worker (SW) and the Director of Nursing (DON) agreed the NAs were neglectful by stepping away from the resident, whom has poor safety awareness due to impaired short term and long term memory. This indicates actual harm for Resident #89 due to leaving the resident unsupervised and out of reach while in the shower resulting in a fall acquired fracture and pain. b) Resident #99 1) Review of the reportable allegation of abuse found a report for Resident #99, dated 05/23/18 at 1:34 AM, this report read Resident told reporter (Employee #6, Social Worker (SW) that she was trying to get out the door to smoke. She tried to get a lighter out of the alleged perpetrator's pocket. While trying to get the resident back into the building, it was alleged that (Employee #59, licensed practical nurse (LPN) grabbed Resident #99's right hand and squeezed her fingers hard causing pain. Resident #99 stated, It hurt real bad. I thought she had broken it. Review of statements found: --Statement by the alleged perpetrator, Employee #59, LPN read: On 05/23/18 at 11:34 AM, Resident #99 was trying to exit through the back door, as I was trying to redirect the resident. The resident was moving wheelchair back into facility the resident grabbed the door frame. I slid my hand under her wrist to guide it backwards. The resident started putting her hand in my pockets, when I asked her not to. At which time resident became agitated and stated, She was going out and we couldn't stop her. then she turned her wheelchair and propelled her self-down the hallway muttering and cursing. --Statement by the nurse whom examined the resident, Employee #23, RN read: This nurse was on East wing, approached by SW and asked to assess (Resident #99's) hand. Resident sitting in her room in her wheelchair at bedside with remote in hand. This nurse asked her if something occurred, she stated, Yes, I don't remember if it was yesterday or today. I was going outside to smoke. I opened the door, I know all the codes. Somebody grabbed my chair, it jerked me backwards. I couldn't go forward or backwards. I saw the girl's lighter in her pocket and I grabbed it. She grabbed my hand and squeezed it real hard. It hurt bad. I thought she broke it. I continued to assess the resident's right hand, this is the hand that was squeezed . 2) This allegation was submitted to Adult Protective Service (APS) on 05/24/18 only. Was not faxed to all of the other required agencies until 05/30/18. Only statements obtained was the perpetrator, Employee #59, LPN and Resident #99. Employee #23, registered nurse (RN) provided a statement with her assessment of Resident 99's injuries (she did not observe the incident). 3) Interview with Resident #99, on 06/05/18 at 9:15 AM, she stated, The staff punishes me with not letting me smoke with the other residents due to I feed the cats my leftover food and cat food that I have bought. They say all kinds of stuff to me, they mock me and they take the food I have for the cats and throws it in the trash can in front of me and says, Ha,Ha. They grab my wheelchair and prevent me from moving and jerks my chair backwards at times. Employee #59 squeezed my hand/fingers one time so hard I thought she broke it. The resident appeared distraught and upset as she recalled these incidents. This deficient practice has caused Resident #99 actual psychosocial and physical harm which caused mental anguish, pain, intimidation, punishment, and humiliation. c) Resident #11 1) Review of Complaint/Concern log found a complaint for Resident #11 dated 03/14/18 and made by the resident's family. The concern stated, (DON's name) received a call from (Name of resident's family) on 03/14/18. Also, another family member was also on the call. The family stated, I want to report abuse. Nurse Aide (NA) #46, is pulling out resident's hair. The family member stated, I have reported this to Employee #23, RN and nothing is been done. The family goes on to say they do not want NA #46 taking care of her as they feel mistreatment by NA #46 is a retaliation due to some criminal activity by residents and NA #46's family. A review of the statements found: --Statement by Director of Nursing (DON) #18, NA #7 and Registered Nurse (RN) dated at 2:00 PM on 03/14/18, statement read: Employee #23, NA #7 and myself (DON) went to the residents room. I asked her if she was happy here and she stated, No, I want to go to[NAME]on. I asked her if everyone is good to her and she stated, They take my stuff. I asked her if anyone has done anything mean to her and she stated, No. I asked her if anyone had smacked her or hit her she stated, No. I asked her if NA #7, RN #23 or myself (DON) had ever pulled her hair and she stated, No. She denied anyone being mean to her and stated they take care of her. --Statement by Employee #46, NA, the alleged perpetrator read: I was putting the resident (Resident #11) to bed after the last smoke break. The resident became combative and I asked the nurse (No name mentioned) to assist me with the resident. She continued hitting and scratching me. We got her in bed and I was removing her jewelry and the necklace pulled her hair. I told her, I was sorry and she said, She was fine and told me to put her stuff on the table. 2) This alleged allegation of abuse/neglect was not reported till 06/15/18 after this Surveyor's inquiry. d) Resident #71 1) A review of the Complaint log found a complaint dated 03/28/18. This complaint was from Resident #71 and was made to the DON. This complaint read: (Resident's name) made a complaint that the staff got her up at 4 am to take a shower. 2) No statements or investigation could be found. After this surveyors intervention it was determined by the staff this was an allegation of neglect/abuse. This was submitted on 06/05/18 to the proper agencies. e) Resident #44 Review of the grievance/concern forms for the last year found three (3) concern/allegations: 1) Allegation #1: On 06/08/17, Resident #44 reported that Licensed Practical Nurse (LPN) #36 did not give her medication to her. The resident reported this to RN #123, who informed the DON. Social Worker (SW) #124 and DON spoke with the resident separately concerning her allegation. Resident denies the allegation of abuse, neglect or anyone treating her in a mean manner. She stated she does not like her nurse because she crushes her medicine. On 06/22/17, resident is no longer receiving medication crushed. Review of the statements found: Statement by Employee #36, LPN, made on 06/01/17 at approximately 1700 (5pm): (Employee #123, RN's name) approached nurse's station and stated, who is (Resident #116's name) nurse? Myself as well as another LPN were sitting at desk when RN #123 states, she needs Tylenol, I explained to RN #123 that this resident did not have a current RX (prescription) for Tylenol. RN #123 states, well you need to give her some Tylenol again I explained, we can call the doctor and ask but most generally she doesn't give Tylenol for a temperature of 99 degrees. Rn #123 states, well I said to give it to her. I explained that I could not give a medication without an order from the physician and again I explained I would contact the physician regarding residents request. I attempted to explain the parameters for Tylenol toxicity due to the resident currently had an order for [REDACTED]. At this time, RN #123 states well you are well within your limits and what could Tylenol hurt? This writer attempted to let Rn #123 know of resident's drug seeking behaviors but that again one of us would contact the physician and let her know the residents request. Statement by Employee #16, LPN on 06/01/17 at 17:40 (5:40 pm): A resident went up to (Employee #123's name) and told her she had a temperature of 99 degrees. The RN came out and told the nurse to give her two (2) Tylenol. Staff attempted to explain to the RN we could not give medication without a physician's orders [REDACTED].#116 two (2) Tylenol. Resident stated she had a temperature of 99 degrees. Staff again attempted that we could not give it. This nurse took RN into the office and attempted to give some of the resident's history with being told I was just an LPN and that she had been a nurse for [AGE] years. Rn became loud to the point that it was almost a scream cutting this nurse off. Statement by Employee #36, LPN on 06/06/17 at approximately 15:10 (3:10 pm) While sitting at nurse's station attempting to complete paperwork to send a resident to hospital. RN #123 is noted to approach the nurse's station and state, I need drugs this writer informed her that I would be with her in just a minute as I was on the telephone attempting to transfer a resident to the hospital. RN #123 states, I wasn't speaking to you, I was speaking to Employee #57, nurse assistant (NA). This writer explained if you are referring to Resident #214's antibiotic then I am his nurse and Employee #57, NA cannot help you. Then Rn #123 stated, I apparently, I didn't make myself clear I was speaking to Employee #57, N[NAME] Again, this writer explained I was the resident's nurse and would get the medication for her in a minute that I am in the process of sending someone to the hospital. RN #123 stated, Obviously, you don't seem to understand that I am not speaking to you. At this time, this writer went into the med room and got the said antibiotic and handed it to the RN #123. RN #123 walks off. Statement by Employee #36, LPN on 06/08/17 at approximately 18:45 (6:45 pm) Front door alarm sounds and this writer proceeds up to the front to check for safety and reset the alarm. I proceeded out to the parking lot to be sure that no residents were in the parking lot unattended. For further safety, this writer walked around building to be sure the parking lot and surrounding areas were clear. This writer then proceeded to the west wing to check with nursing staff to be sure all residents were accounted for. Upon entering front hall of the east wing (Employee #123, RN name) was noted to be standing at the nurses station with the Medication Administration Report (MAR) for the A section opened. This writer enters the nurses station to begin charting on the computer when Employee #123, RN states, You did not give (Resident #44' name) her meds today. At this time this writer states, yes I did. Employee #123, RN then states, Well, I don't think you did. She told me you didn't. I explained to the RN that the resident has hoarding behaviors, refusal of medications and false accusations. The RN then states, Well if she says you didn't give the medication, as far as I concerned you didn't. RN proceeds to state, There are no initials in the box (referring to the MAR). Then asked, Is 0900 9am or pm. At this time, I stated 0900 is 9am and I have been checking my MAR to be sure all of my finger sticks and etc. has been documented. RN then states, Well, apparently you did not learn anything in nursing school, you are to sign medication out when you give them, therefore, as far as I am concerned you did not give her medication and that is abuse. At no time did the RN allow me to see which area of MAR that she was referring to and nor did she know the resident had been found with a [MEDICATION NAME] (pain medication) in her bra. While attempting to explain this resident's behavior the RN became loud and she pointed her finger in this writers face and saying, Where were you when I was looking for you. I explained I was assessing the situation with the door alarm going off and being sure there was no elopement, while she sat in the office not responding. She (RN) continued to point finger in this writer's face. This writer states, please get your finger out of my face. RN states, you need to get in the office to continue this conversation. This writer informed the RN , I will not go to a private area to hold a conversation with you alone. You are pointing your finger in my face and approached me here in front of my peers and other residents. So, I will not go to a private area with you if you want to speak to me I will do it in front of the DON only. At this time, the RN looks to her right where several staff as well as residents in the hallway. The RN then states, (Employee #57, NA name) go to the office. At this time this writer explained that the NA was a union representative but as a union employee I did not wish to have her present to speak with the RN without the DON in the building due to her aggressive tone with me. RN states, Well, we will see about this I am calling the DON. At no time during this shift did this RN look at any other MAR located on the east wing or any other resident's MAR regarding medications or administration. But the RN stated, Well she is my family and I will take care of this. Statement by Employee #125, SW read, On 06/09/17, I spoke with resident, (Resident #44's Name), regarding allegations a nurse made that the resident was not getting her medications. (Resident #44's name) came to my office in private and I asked her if any nurse failed to give her medications to her. The resident stated, No, I get my medication but she makes me take them crushed and I don't like that. I then looked in the resident's chart to verify that the resident had an physician's orders [REDACTED]. There was a fact an order stating that the resident was to receive crushed meds. I explained this to the resident and she stated her understanding. Statement by Employee #60. LPN read, On 06/11/17, I worked the A hallway on the west wing and (Employee #39, LPN name) worked B hallway. She came to me with a [MEDICATION NAME] (pain medication) in a cup and asked me to waste it with her. She stated she had popped it out in error when pulling a residents medicine, Medication was wasted. We counted at the end of shift and a [MEDICATION NAME](pain med) was signed out by Employee #39 for 06/11/17 at 9 pm and count was correct. This allegation of abuse/neglect was never reported to the required state agencies. 2) Allegation #2: Resident #44 reported an allegation of neglect on 06/12/17 to RN #123. RN #123 reported teh allgeation to the Nursing Home Administrator and DON. The allegation made by the resident was not given her medication by LPN #123. LPN #123 went to the resident's room to confront the resident by reportedly saying, Since you told on me now your medication will be crushed and I will give them to you in the hallway. Employee #124, social worker (SW) talked with resident regarding the allegations and resident denies the allegation. The resident continues to deny any issues with staff being mean to her. She continues to be upset about her medications being crushed. A review of the statements found: --Statement by Employee #44, RN, made on 06/12/17 at 5:35 p.m.: While doing skin assessments, patient in room [ROOM NUMBER]- (Resident #112, Name) called me into her room. She asked me if I was a nurse and I told her yes. Resident stated she did not receive her 9 pm meds last night. I asked her did she know what med, she stated little blue pill (pain pill- [MEDICATION NAME]). I told her I would check the MAR (Medication Administration Record), it may have been not available. I checked the MAR and the medication ([MEDICATION NAME]) had been signed out with the initials of (Employee #39, LPN). I went back into Resident #112's room with Employee #125, Graduate Nurse (GN). What month is it? she stated, June. I asked the year, she stated, (YEAR). I asked her who was the President, she said, Trump. I asked her if she was mistaken, she said, No, I check my pills, my pain pill is the little blue pill and it wasn't there. And I asked the nurse (Employee #39) about it and she told she didn't have it and that they would give it at 12:00 a.m. She went on to tell me several nurses about it and nobody came to see her. --Statement by Employee #49, NA read: On (MONTH) 12, (YEAR) (time ineligible) I was putting (Name of Resident #76) in bed. The wife of Resident #76 was in the room. Employee #124, RN came in the room to do an assessment on the resident. The RN #124 started talking to the resident's wife about an incident that happened on east hallway. She told the wife it involved Resident #44 and Employee #36, LPN. She said she was in the bathroom and heard everything between Resident #44 and LPN #36. She told the wife she had took it to the Administrator and the DON. She told the wife she had screen shot all the nurses whom had been notified. She said they were that the facility was trying to get rid of her and that she reported it to the state. On (MONTH) 20, (YEAR) the wife of Resident #76 was told by RN #124 this morning she had received her letter from the state and they were investigated. --Statement by Employee #41, NA, written on 06/12/17 read: I witnessed a resident come up to the RN and asked about her medicine, The RN came up to the nurse's station and asked where the nurse was at. The RN started looking through the medicine book and when the LPN came back to the nurse's station the RN asked the LPN about the resident's medicine and the MAR book. The RN was telling the LPN she must have not learned anything or she would have signed the book when she gave the resident meds. RN points at LPN and asked her to come to the office. LPN asked the RN to stop pointing her finger in her face. The RN said I'm not pointing in your face. --Statement by Employee #125, SW, written on 06/12/17 read: On 06/12/17, SW spoke with (Resident #44's name), regarding allegations the LPN #36 had not gave her medications and that she came into her room and stated, Since you told on me now your meds will be crushed and I will give it to you in the hall. Resident #44 denies that this was said and also says, Nobody has been mean to me here but I don't like that nurse (LPN #36) because she crushes my meds. --Statement by Employee #127, NA written on 06/12/17 read; I witnessed Resident #44 go into the DON's office and told RN #124 she had not had any of her medicine all day. The RN looked at the MAR and the book had holes in it where the LPN had not signed the MAR. The LPN assured the RN she had gave the meds but had not signed the MAR. The RN's and the LPN's voices kept getting louder. This allegation of abuse/neglect was never reported to the required agencies. 3) Allegation #3: A review of the concern/grievance log found a statement on 06/20/17 at approximately 9:00 AM, NA #58 entered Resident #44's room to find her roommate some clothes, this resident had her roommates pants on. I came out and got my nurse (LPN #36) to assist me. The housekeeper and I was standing in the closet doorway and Resident #44 exited the bathroom holding the clothes. The resident threw the pants and hit LPN #36 in the side of head and then openly smacked her across the face knocking her glasses off. I attempted to get the resident away from the nurse and calm her down. The resident started yelling at the nurse stating, I am going to have your job [***] . I dare you to hit me queer. --Statement by Employee #36, LPN dated 06/20/17 at 9:15 am read: Upon entering Resident #44's room I found the resident had her roommates pants on. This writer, NA and Housekeeper were standing in the doorway of this resident's room when she exited the bathroom striking this nurse in left side of face multiple times screaming, (RN #124) and I are going to have your job [***] . I dare you to hit me I'm calling RN #124 and she will beat your face in. This writer exited the room and notified the supervisor of this resident's behaviors and notified the physician with new orders to administer [MEDICATION NAME] 20 milligrams (mg) intramuscularly (IM) now for agitation. Power of attorney (POA) notified and made aware of residents room change from east to west wing. --Statement by Employee #125, SW read: On 06/20/17, I talked with Resident #44, to discuss her recent behaviors against LPN #36. I asked (Resident #44) why she hit LPN#36 and the resident stated the nurse was discrimating against her. I then asked her why she felt LPN #36 was discriminating against her and she stated, She crushes my medicine and RN #124 told me it was discrimation. I then asked the resident why she called the LPN #36 a queer. She at first denied calling her a queer but later she said, RN #124 told me that she was married to a girl so what would you call her. I told the resident that she could not act that way toward a staff member regardless of her personal opinion. The resident states understanding. This incident of alleged abuse/neglect was never entered on a Complaint/Grievance form and was never reported to the appropriate agencies. f) Residents in room [ROOM NUMBER] on 06/19/17 1) A review of grievance/concern book found an incident, in which, occurred between RN #124 and Employee NA #54 on 06/19/17 at 9:30 PM. Review of the statements found: --Statement by Employee #124, RN read, On 06/19/17 at around 9:30 pm I went to find who had Resident #117 to do a skin assessment. The NAs stated that NA #54 had Resident #117. I went into room [ROOM NUMBER]and pecked on the door, when I entered the room I said, Good I need to do (Resident #118's skin assessment and you have her undressed. NA #54 said, Why you want to look at her ass. I asked him what he meant by that and he said, I don't have time for this. I told him I needed him to help me turn Resident #117 on her side for a skin assessment that I had already did everything but her buttock and back. NA #54 stated, I have more patients to do and you treat NAs and nurses like were dirt under her feet. I told him that wasn't true and I hadn't even talked to him before, that I was told to get help turning the patients and he kept saying you never asked. I asked again for help and he refused. I told him I was going to write him up for insubordination and he stated, I am getting a union representative. As I came down the hall I stated, I hate it when people are smart asses. Statement by Employee #54, NA read: I was on west wing and was in room [ROOM NUMBER] assisting the residents in getting ready for bed, when RN #124 came into the room and told me that I was to come to room [ROOM NUMBER]. I asked her to give me a minute, she then told me that she needed me to do it now. I told her she needed to give me a minute. I asked her if she needed to look at their butt. She then told me I was getting wrote up for insubordination. I never refused to help. I told her to give me a minute. Then she yelled at me and called me a smartass. She stated she was the RN and that meant I would do as I am told and not question her. She pulled her name badge at my face and said that is what this means. 2) This allegation of abuse and neglect was not reported till after this Surveyor's inquiry of situation. It was reported on 06/08/18 (a year after the occurrence). g) Resident #58 1) A review of the Complaint/Grievance book found a concern by Resident #58. This allegation was reported to Employee #125, SW on 01/23/18. Concern: Resident reports that she doesn't know how to take the Employee #43, NA on evening shift. NA sometimes. She takes good care of me but she likes to joke and sometimes doesn't know how to take her. She makes me anxious. Interventions: NA #43 received a written warning. The resident no longer has the NA as her caregiver. 2) No further statements could be located. This allegation of abuse/neglect was not reported until after this Surveyors inquiry. Reported on 06/05/18 to the required agencies. h) Resident #4 1) A review of the complaint/grievance book found a concern by Resident #4. This allegation was reported to SW #6 on 06/01/18. Concerns noted by Resident #4's family read: Still not getting coffee at all meals. Staff were mocking the resident Help at the west wing nurses' station. One NA would not give the NA caring for Resident #4 the proper size of diapers. Wednesday, pm shift. The resident was lying angled in her bed. She couldn't get to her tray to eat. She had a bowl of peaches in her bed with her. She needs pulled up to the tray to eat her meals. Residents name is not over her bed it is a different residents' name. Interventions: Coffee is being served at all meals. Diaper issue is resolved. Resident will eat in day lounge (sitting upward). 2) No further statements could be located. This allegation of abuse/neglect was not reported until after this Surveyors inquiry. Reported on 06/05/18 to the required agencies. i) Complaint made by the Ombudsman 1) A review of the complaint/grievance book found a concern by the Ombudsman. This allegation was reported to SW #6 on 05/15/18. Concern: I had more complaints of staff being rude to residents. One employee (NA) was huffing and puffing and complaining because they were short staffed and everyone was acting crazy. After the visitor reported this a resident spoke up and reported a nurse who is mean and hateful and this nurse had to shut up and quit talking so much. The NA said that is her personality. There is one employee that is hateful as the devil; when one resident asked for a drink and another asked if there was church tonight; she yelled and was hateful to both residents. Please address this issue with your staff. 2) This surveyor was provided a copy of an in-service for Ethical behavior and Unethical behavior conducted on 05/16/18 by the Administrator. 3) No further statements could be located. This allegation of abuse/neglect was not reported until after this Surveyors inquiry. Reported on 06/06/18 to the required agencies. j) Resident #114 1) Review of Resident #114's medical records found the resident was admitted on [DATE]. Care Plan initiated; Resident is a 53yr. old female-Diagnosis: [REDACTED]. Staff supervises meals, assists as needed. She is noted to take food from other resident's trays. Easily agitated. Diet Regular NAS with lidded cups for safety. Weight 102# --below IBW range (123#-149#) She feeds herself meals--often uses her fingers to eat --likes sweets and snack foods. No teeth or dentures. 2) Progress notes found the following incident/altercations involving resident-to-resident: --10/18/2017 at 08:28 - Resident noted to be up walking around day lounge throwing food on the floor and taking food from other resident's trays. --10/19/2017 at 18:00 - Resident up and ambulating in day lounge throwing her shoes across room pushing furniture against resident's wheelchairs. staff sits down with resident to assist with meal resident then gets up and proceeds to remove food from her brother's tray. when attempting to redirect resident begins hitting self in head and slamming fists on wall, offered activities, fluids and snacks with staff to monitor for safety. --11/6/2017 at 18:00 - Another resident was calling out to resident and calling her names. Resident became agitated and grabbed other resident's hair and pulled hard. Residents were separated by staff. Vital signs unable to be obtained due to resident was agitated. --11/9/2017 at 21:46 - Late Entry: Note: resident has been noted to be up wandering in other resident's rooms, taking food and drinks off resident's dinner trays this shift requiring redirection numerous times. --11/27/2017 at 07:59 - Resident up ambulating in day lounge removing food from other resident's trays requiring redirection numerous times. resident becomes agitated and begins hitting self in head. attempts to take resident to room for self-soothing. --12/7/2017 at 13:20 - Resident in day lounge at this time alert and nonverbal skin clean dry warm to touch resident noted to hit her head on the walls and glass numerous times this shift , staff makes attempts to redirect this resident , with no positive results noted , this resident noted to be grabbing other residents chairs in the day lounge and halls x 4 this shift staff attempts to redirect this resident to the day lounge resident placed in chair at which time resident proceeds to kick and hit staff numerous times along with attempting to hit her head on tables and chairs in the day lounge , staff remains with resident at this time. --12/7/2017 at 17:40 - Resident continues to be aggressive to staff along with continues to hit her head on the walls and windows, with each attempt to redirect (TRUNCATED)",2020-09-01
2273,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2018-06-12,610,H,0,1,ZFV511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record, Incident/Accident reports, Complaints/Grievances and Reportable reports, staff interview, and resident interview, the facility failed to ensure each allegation of abuse and/or neglect were thoroughly investigated to prevent further potential abuse, neglect and mistreatment. This deficient practice caused actual harm for Residents #89, #99, #26 and #5. This deficient practice had the potential to affect more than an isolated number. Resident identifiers: #89, #99, #26, #11, #71, #5, #44, #58, #4, #212, #114. Facility census: 107. Findings included: a) Resident #89 1) Review of Resident #89's medical records found an annual Minimum Data Set (MDS) with an Assessment reference date (ARD) of 11/07/18. This MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 for severe cognitive impairment. Resident # 89's [DIAGNOSES REDACTED]. Severe confusion was noted with poor safety awareness with a history of falls. Resident #89 required the physical assistance of one person with bathing/showering. Resident #89 was noted as always continent of bowel and bladder functions. Requiring only supervision with most Activities of Daily living except bathing and personal hygiene. 2) A review of the Incident/Accident reports found on 02/01/18 at 10:20 AM found an incident occurred in the shower room. The incident description was as follows: Called to shower room per staff. Resident sitting in floor in shower room. Resident noted to have a complaint of pain in left wrist. Left wrist noted to be swollen at this time. Resident has no other complaints of pain. No redness or bruising noted at this time. Resident was unable to give description states, My wrist is really hurting me. Resident noted to be holding left wrist at this time. Resident was transferred to nearby hospital and was diagnosed with [REDACTED]. A review of statements by the two (2) nurse aides (NA) present in the shower room found: --Statement by Employee #56, NA read: I was showering (Resident #89's name) with another staff member in the shower room. As I turned to get a piece of clothing the resident got up and tried to walk by herself and lost her footing and fall the other staff member (Employee #43, NA) tried to catch her but wasn't quick enough then got (Employee #32, licensed practical nurse (LPN) name. --Statement by Employee #43, NA read: I was assisting another staff member in showering resident (Resident #89). As the other staff member turned to get a piece of the resident's clothing. Resident got up unassisted. She lost her footing. I tried to catch her but I was too late. 3) Review of the significant change MDS with an ARD of 05/09/18 found the resident has had a decline in her activities of daily living (ADL) and has more episodes of incontinence. Resident remains alert to person only and continues to have poor safety awareness secondary to impaired cognitive status. This indicates following the incident on 02/01/18 resulting in a fractured left wrist, Resident #89 has experienced a decline in her ADL status and incontinence status. 4) On 02/02/18 at 11:00 AM an in-service was provided on Proper showering techniques the following was included, Maintain a face-to-face contact when possible, stay with resident during the entire process . do not leave residents alone while bathing or showering . 5) This incident was not reported as potential neglect until 06/12/18 (after surveyor intervention). The Social Worker (SW) and the Director of Nursing (DON) agreed the NAs were neglectful by stepping away from the resident, whom has poor safety awareness due to impaired short term and long term memory. This indicates actual harm for Resident #89 due to leaving the resident unsupervised and out of reach while in the shower resulting in a fall acquired fracture and pain. No evidence was found or provided to support the facility conducted a thorough investigation or put interventions in place to protect the resident. b) Resident #99 1) Review of the reportable allegation of abuse found a report for Resident #99, dated 05/23/18 at 1:34 AM, this report read Resident told reporter (Employee #6, Social Worker (SW) that she was trying to get out the door to smoke. She tried to get a lighter out of the alleged perpetrator's pocket. While trying to get the resident back into the building, it was alleged that (Employee #59, licensed practical nurse (LPN) grabbed Resident #99's right hand and squeezed her fingers hard causing pain. Resident #99 stated, It hurt real bad. I thought she had broken it. Review of statements found: --Statement by the alleged perpetrator, Employee #59, LPN read: On 05/23/18 at 11:34 AM, Resident #99 was trying to exit through the back door, as I was trying to redirect the resident. The resident was moving wheelchair back into facility the resident grabbed the door frame. I slid my hand under her wrist to guide it backwards. The resident started putting her hand in my pockets, when I asked her not to. At which time resident became agitated and stated, She was going out and we couldn't stop her. then she turned her wheelchair and propelled her self-down the hallway muttering and cursing. --Statement by the nurse whom examined the resident, Employee #23, RN read: This nurse was on East wing, approached by SW and asked to assess (Resident #99's) hand. Resident sitting in her room in her wheelchair at bedside with remote in hand. This nurse asked her if something occurred, she stated, Yes, I don't remember if it was yesterday or today. I was going outside to smoke. I opened the door, I know all the codes. Somebody grabbed my chair, it jerked me backwards. I couldn't go forward or backwards. I saw the girl's lighter in her pocket and I grabbed it. She grabbed my hand and squeezed it real hard. It hurt bad. I thought she broke it. I continued to assess the resident's right hand, this is the hand that was squeezed . 2) This allegation was submitted to Adult Protective Service (APS) on 05/24/18 only. Was not faxed to all of the other required agencies until 05/30/18. Only statements obtained was the perpetrator, Employee #59, LPN and Resident #99. Employee #23, registered nurse (RN) provided a statement with her assessment of Resident 99's injuries (she did not observe the incident). 3) Interview with Resident #99, on 06/05/18 at 9:15 AM, she stated, The staff punishes me with not letting me smoke with the other residents due to I feed the cats my leftover food and cat food that I have bought. They say all kinds of stuff to me, they mock me and they take the food I have for the cats and throws it in the trash can in front of me and says, Ha,Ha. They grab my wheelchair and prevent me from moving and jerks my chair backwards at times. Employee #59 squeezed my hand/fingers one time so hard I thought she broke it. The resident appeared distraught and upset as she recalled these incidents. No evidence was found or provided to support the facility conducted a thorough investigation or put interventions in place to protect the resident. This deficient practice has caused Resident #99 actual psychosocial and physical harm which caused mental anguish, pain, intimidation, punishment, and humiliation. c) Resident #11 1) Review of Complaint/Concern log found a complaint for Resident #11 dated 03/14/18 and made by the resident's family. The concern stated, (DON's name) received a call from (Name of resident's family) on 03/14/18. Also, another family member was also on the call. The family stated, I want to report abuse. Nurse Aide (NA) #46, is pulling out resident's hair. The family member stated, I have reported this to Employee #23, RN and nothing is been done. The family goes on to say they do not want NA #46 taking care of her as they feel mistreatment by NA #46 is a retaliation due to some criminal activity by residents and NA #46's family. A review of the statements found: --Statement by Director of Nursing (DON) #18, NA #7 and Registered Nurse (RN) dated at 2:00 PM on 03/14/18, statement read: Employee #23, NA #7 and myself (DON) went to the residents room. I asked her if she was happy here and she stated, No, I want to go to[NAME]on. I asked her if everyone is good to her and she stated, They take my stuff. I asked her if anyone has done anything mean to her and she stated, No. I asked her if anyone had smacked her or hit her she stated, No. I asked her if NA #7, RN #23 or myself (DON) had ever pulled her hair and she stated, No. She denied anyone being mean to her and stated they take care of her. --Statement by Employee #46, NA, the alleged perpetrator read: I was putting the resident (Resident #11) to bed after the last smoke break. The resident became combative and I asked the nurse (No name mentioned) to assist me with the resident. She continued hitting and scratching me. We got her in bed and I was removing her jewelry and the necklace pulled her hair. I told her, I was sorry and she said, She was fine and told me to put her stuff on the table. 2) This alleged allegation of abuse/neglect was not reported till 06/15/18 after this Surveyor's inquiry. No evidence was found or provided to support the facility conducted a thorough investigation or put interventions in place to protect the resident. d) Resident #71 1) A review of the Complaint log found a complaint dated 03/28/18. This complaint was from Resident #71 and was made to the DON. This complaint read: (Resident's name) made a complaint that the staff got her up at 4 am to take a shower. 2) No statements or investigation could be found. After this surveyors intervention it was determined by the staff this was an allegation of neglect/abuse. This was submitted on 06/05/18 to the proper agencies. No evidence was found or provided to support the facility conducted a thorough investigation or put interventions in place to protect the resident. e) Resident #44 Review of the grievance/concern forms for the last year found three (3) concern/allegations: 1) Allegation #1: On 06/08/17, Resident #44 reported that Licensed Practical Nurse (LPN) #36 did not give her medication to her. The resident reported this to RN #123, who informed the DON. Social Worker (SW) #124 and DON spoke with the resident separately concerning her allegation. Resident denies the allegation of abuse, neglect or anyone treating her in a mean manner. She stated she does not like her nurse because she crushes her medicine. On 06/22/17, resident is no longer receiving medication crushed. Review of the statements found: Statement by Employee #36, LPN, made on 06/01/17 at approximately 1700 (5pm): (Employee #123, RN's name) approached nurse's station and stated, who is (Resident #116's name) nurse? Myself as well as another LPN were sitting at desk when RN #123 states, she needs Tylenol, I explained to RN #123 that this resident did not have a current RX (prescription) for Tylenol. RN #123 states, well you need to give her some Tylenol again I explained, we can call the doctor and ask but most generally she doesn't give Tylenol for a temperature of 99 degrees. Rn #123 states, well I said to give it to her. I explained that I could not give a medication without an order from the physician and again I explained I would contact the physician regarding residents request. I attempted to explain the parameters for Tylenol toxicity due to the resident currently had an order for [REDACTED]. At this time, RN #123 states well you are well within your limits and what could Tylenol hurt? This writer attempted to let Rn #123 know of resident's drug seeking behaviors but that again one of us would contact the physician and let her know the residents request. Statement by Employee #16, LPN on 06/01/17 at 17:40 (5:40 pm): A resident went up to (Employee #123's name) and told her she had a temperature of 99 degrees. The RN came out and told the nurse to give her two (2) Tylenol. Staff attempted to explain to the RN we could not give medication without a physician's orders [REDACTED].#116 two (2) Tylenol. Resident stated she had a temperature of 99 degrees. Staff again attempted that we could not give it. This nurse took RN into the office and attempted to give some of the resident's history with being told I was just an LPN and that she had been a nurse for [AGE] years. Rn became loud to the point that it was almost a scream cutting this nurse off. Statement by Employee #36, LPN on 06/06/17 at approximately 15:10 (3:10 pm) While sitting at nurse's station attempting to complete paperwork to send a resident to hospital. RN #123 is noted to approach the nurse's station and state, I need drugs this writer informed her that I would be with her in just a minute as I was on the telephone attempting to transfer a resident to the hospital. RN #123 states, I wasn't speaking to you, I was speaking to Employee #57, nurse assistant (NA). This writer explained if you are referring to Resident #214's antibiotic then I am his nurse and Employee #57, NA cannot help you. Then Rn #123 stated, I apparently, I didn't make myself clear I was speaking to Employee #57, N[NAME] Again, this writer explained I was the resident's nurse and would get the medication for her in a minute that I am in the process of sending someone to the hospital. RN #123 stated, Obviously, you don't seem to understand that I am not speaking to you. At this time, this writer went into the med room and got the said antibiotic and handed it to the RN #123. RN #123 walks off. Statement by Employee #36, LPN on 06/08/17 at approximately 18:45 (6:45 pm) Front door alarm sounds and this writer proceeds up to the front to check for safety and reset the alarm. I proceeded out to the parking lot to be sure that no residents were in the parking lot unattended. For further safety, this writer walked around building to be sure the parking lot and surrounding areas were clear. This writer then proceeded to the west wing to check with nursing staff to be sure all residents were accounted for. Upon entering front hall of the east wing (Employee #123, RN name) was noted to be standing at the nurses station with the Medication Administration Report (MAR) for the A section opened. This writer enters the nurses station to begin charting on the computer when Employee #123, RN states, You did not give (Resident #44' name) her meds today. At this time this writer states, yes I did. Employee #123, RN then states, Well, I don't think you did. She told me you didn't. I explained to the RN that the resident has hoarding behaviors, refusal of medications and false accusations. The RN then states, Well if she says you didn't give the medication, as far as I concerned you didn't. RN proceeds to state, There are no initials in the box (referring to the MAR). Then asked, Is 0900 9am or pm. At this time, I stated 0900 is 9am and I have been checking my MAR to be sure all of my finger sticks and etc. has been documented. RN then states, Well, apparently you did not learn anything in nursing school, you are to sign medication out when you give them, therefore, as far as I am concerned you did not give her medication and that is abuse. At no time did the RN allow me to see which area of MAR that she was referring to and nor did she know the resident had been found with a [MEDICATION NAME] (pain medication) in her bra. While attempting to explain this resident's behavior the RN became loud and she pointed her finger in this writers face and saying, Where were you when I was looking for you. I explained I was assessing the situation with the door alarm going off and being sure there was no elopement, while she sat in the office not responding. She (RN) continued to point finger in this writer's face. This writer states, please get your finger out of my face. RN states, you need to get in the office to continue this conversation. This writer informed the RN , I will not go to a private area to hold a conversation with you alone. You are pointing your finger in my face and approached me here in front of my peers and other residents. So, I will not go to a private area with you if you want to speak to me I will do it in front of the DON only. At this time, the RN looks to her right where several staff as well as residents in the hallway. The RN then states, (Employee #57, NA name) go to the office. At this time this writer explained that the NA was a union representative but as a union employee I did not wish to have her present to speak with the RN without the DON in the building due to her aggressive tone with me. RN states, Well, we will see about this I am calling the DON. At no time during this shift did this RN look at any other MAR located on the east wing or any other resident's MAR regarding medications or administration. But the RN stated, Well she is my family and I will take care of this. Statement by Employee #125, SW read, On 06/09/17, I spoke with resident, (Resident #44's Name), regarding allegations a nurse made that the resident was not getting her medications. (Resident #44's name) came to my office in private and I asked her if any nurse failed to give her medications to her. The resident stated, No, I get my medication but she makes me take them crushed and I don't like that. I then looked in the resident's chart to verify that the resident had an physician's orders [REDACTED]. There was a fact an order stating that the resident was to receive crushed meds. I explained this to the resident and she stated her understanding. Statement by Employee #60. LPN read, On 06/11/17, I worked the A hallway on the west wing and (Employee #39, LPN name) worked B hallway. She came to me with a [MEDICATION NAME] (pain medication) in a cup and asked me to waste it with her. She stated she had popped it out in error when pulling a residents medicine, Medication was wasted. We counted at the end of shift and a [MEDICATION NAME](pain med) was signed out by Employee #39 for 06/11/17 at 9 pm and count was correct. This allegation of abuse/neglect was never reported to the required state agencies. 2) Allegation #2: Resident #44 reported an allegation of neglect on 06/12/17 to RN #123. RN #123 reported teh allgeation to the Nursing Home Administrator and DON. The allegation made by the resident was not given her medication by LPN #123. LPN #123 went to the resident's room to confront the resident by reportedly saying, Since you told on me now your medication will be crushed and I will give them to you in the hallway. Employee #124, social worker (SW) talked with resident regarding the allegations and resident denies the allegation. The resident continues to deny any issues with staff being mean to her. She continues to be upset about her medications being crushed. A review of the statements found: --Statement by Employee #44, RN, made on 06/12/17 at 5:35 p.m.: While doing skin assessments, patient in room [ROOM NUMBER]- (Resident #112, Name) called me into her room. She asked me if I was a nurse and I told her yes. Resident stated she did not receive her 9 pm meds last night. I asked her did she know what med, she stated little blue pill (pain pill- [MEDICATION NAME]). I told her I would check the MAR (Medication Administration Record), it may have been not available. I checked the MAR and the medication ([MEDICATION NAME]) had been signed out with the initials of (Employee #39, LPN). I went back into Resident #112's room with Employee #125, Graduate Nurse (GN). What month is it? she stated, June. I asked the year, she stated, (YEAR). I asked her who was the President, she said, Trump. I asked her if she was mistaken, she said, No, I check my pills, my pain pill is the little blue pill and it wasn't there. And I asked the nurse (Employee #39) about it and she told she didn't have it and that they would give it at 12:00 a.m. She went on to tell me several nurses about it and nobody came to see her. --Statement by Employee #49, NA read: On (MONTH) 12, (YEAR) (time ineligible) I was putting (Name of Resident #76) in bed. The wife of Resident #76 was in the room. Employee #124, RN came in the room to do an assessment on the resident. The RN #124 started talking to the resident's wife about an incident that happened on east hallway. She told the wife it involved Resident #44 and Employee #36, LPN. She said she was in the bathroom and heard everything between Resident #44 and LPN #36. She told the wife she had took it to the Administrator and the DON. She told the wife she had screen shot all the nurses whom had been notified. She said they were that the facility was trying to get rid of her and that she reported it to the state. On (MONTH) 20, (YEAR) the wife of Resident #76 was told by RN #124 this morning she had received her letter from the state and they were investigated. --Statement by Employee #41, NA, written on 06/12/17 read: I witnessed a resident come up to the RN and asked about her medicine, The RN came up to the nurse's station and asked where the nurse was at. The RN started looking through the medicine book and when the LPN came back to the nurse's station the RN asked the LPN about the resident's medicine and the MAR book. The RN was telling the LPN she must have not learned anything or she would have signed the book when she gave the resident meds. RN points at LPN and asked her to come to the office. LPN asked the RN to stop pointing her finger in her face. The RN said I'm not pointing in your face. --Statement by Employee #125, SW, written on 06/12/17 read: On 06/12/17, SW spoke with (Resident #44's name), regarding allegations the LPN #36 had not gave her medications and that she came into her room and stated, Since you told on me now your meds will be crushed and I will give it to you in the hall. Resident #44 denies that this was said and also says, Nobody has been mean to me here but I don't like that nurse (LPN #36) because she crushes my meds. --Statement by Employee #127, NA written on 06/12/17 read; I witnessed Resident #44 go into the DON's office and told RN #124 she had not had any of her medicine all day. The RN looked at the MAR and the book had holes in it where the LPN had not signed the MAR. The LPN assured the RN she had gave the meds but had not signed the MAR. The RN's and the LPN's voices kept getting louder. This allegation of abuse/neglect was never reported to the required agencies. 3) Allegation #3: A review of the concern/grievance log found a statement on 06/20/17 at approximately 9:00 AM, NA #58 entered Resident #44's room to find her roommate some clothes, this resident had her roommates pants on. I came out and got my nurse (LPN #36) to assist me. The housekeeper and I was standing in the closet doorway and Resident #44 exited the bathroom holding the clothes. The resident threw the pants and hit LPN #36 in the side of head and then openly smacked her across the face knocking her glasses off. I attempted to get the resident away from the nurse and calm her down. The resident started yelling at the nurse stating, I am going to have your job [***] . I dare you to hit me queer. --Statement by Employee #36, LPN dated 06/20/17 at 9:15 am read: Upon entering Resident #44's room I found the resident had her roommates pants on. This writer, NA and Housekeeper were standing in the doorway of this resident's room when she exited the bathroom striking this nurse in left side of face multiple times screaming, (RN #124) and I are going to have your job [***] . I dare you to hit me I'm calling RN #124 and she will beat your face in. This writer exited the room and notified the supervisor of this resident's behaviors and notified the physician with new orders to administer [MEDICATION NAME] 20 milligrams (mg) intramuscularly (IM) now for agitation. Power of attorney (POA) notified and made aware of residents room change from east to west wing. --Statement by Employee #125, SW read: On 06/20/17, I talked with Resident #44, to discuss her recent behaviors against LPN #36. I asked (Resident #44) why she hit LPN#36 and the resident stated the nurse was discrimating against her. I then asked her why she felt LPN #36 was discriminating against her and she stated, She crushes my medicine and RN #124 told me it was discrimation. I then asked the resident why she called the LPN #36 a queer. She at first denied calling her a queer but later she said, RN #124 told me that she was married to a girl so what would you call her. I told the resident that she could not act that way toward a staff member regardless of her personal opinion. The resident states understanding. This incident of alleged abuse/neglect was never entered on a Complaint/Grievance form and was never reported to the appropriate agencies. No evidence was found or provided to support the facility conducted a thorough investigation or put interventions in place to protect the resident. f) Residents in room [ROOM NUMBER] on 06/19/17 1) A review of grievance/concern book found an incident, in which, occurred between RN #124 and Employee NA #54 on 06/19/17 at 9:30 PM. Review of the statements found: --Statement by Employee #124, RN read, On 06/19/17 at around 9:30 pm I went to find who had Resident #117 to do a skin assessment. The NAs stated that NA #54 had Resident #117. I went into room [ROOM NUMBER]and pecked on the door, when I entered the room I said, Good I need to do (Resident #118's skin assessment and you have her undressed. NA #54 said, Why you want to look at her ass. I asked him what he meant by that and he said, I don't have time for this. I told him I needed him to help me turn Resident #117 on her side for a skin assessment that I had already did everything but her buttock and back. NA #54 stated, I have more patients to do and you treat NAs and nurses like were dirt under her feet. I told him that wasn't true and I hadn't even talked to him before, that I was told to get help turning the patients and he kept saying you never asked. I asked again for help and he refused. I told him I was going to write him up for insubordination and he stated, I am getting a union representative. As I came down the hall I stated, I hate it when people are smart asses. Statement by Employee #54, NA read: I was on west wing and was in room [ROOM NUMBER] assisting the residents in getting ready for bed, when RN #124 came into the room and told me that I was to come to room [ROOM NUMBER]. I asked her to give me a minute, she then told me that she needed me to do it now. I told her she needed to give me a minute. I asked her if she needed to look at their butt. She then told me I was getting wrote up for insubordination. I never refused to help. I told her to give me a minute. Then she yelled at me and called me a smartass. She stated she was the RN and that meant I would do as I am told and not question her. She pulled her name badge at my face and said that is what this means. 2) This allegation of abuse and neglect was not reported till after this Surveyor's inquiry of situation. It was reported on 06/08/18 (a year after the occurrence). No evidence was found or provided to support the facility conducted a thorough investigation or put interventions in place to protect the resident. g) Resident #58 1) A review of the Complaint/Grievance book found a concern by Resident #58. This allegation was reported to Employee #125, SW on 01/23/18. Concern: Resident reports that she doesn't know how to take the Employee #43, NA on evening shift. NA sometimes. She takes good care of me but she likes to joke and sometimes doesn't know how to take her. She makes me anxious. Interventions: NA #43 received a written warning. The resident no longer has the NA as her caregiver. 2) No further statements could be located. This allegation of abuse/neglect was not reported until after this Surveyors inquiry. Reported on 06/05/18 to the required agencies. No evidence was found or provided to support the facility conducted a thorough investigation or put interventions in place to protect the resident. h) Resident #4 1) A review of the complaint/grievance book found a concern by Resident #4. This allegation was reported to SW #6 on 06/01/18. Concerns noted by Resident #4's family read: Still not getting coffee at all meals. Staff were mocking the resident Help at the west wing nurses' station. One NA would not give the NA caring for Resident #4 the proper size of diapers. Wednesday, pm shift. The resident was lying angled in her bed. She couldn't get to her tray to eat. She had a bowl of peaches in her bed with her. She needs pulled up to the tray to eat her meals. Residents name is not over her bed it is a different residents' name. Interventions: Coffee is being served at all meals. Diaper issue is resolved. Resident will eat in day lounge (sitting upward). 2) No further statements could be located. This allegation of abuse/neglect was not reported until after this Surveyors inquiry. Reported on 06/05/18 to the required agencies. i) Complaint made by the Ombudsman 1) A review of the complaint/grievance book found a concern by the Ombudsman. This allegation was reported to SW #6 on 05/15/18. Concern: I had more complaints of staff being rude to residents. One employee (NA) was huffing and puffing and complaining because they were short staffed and everyone was acting crazy. After the visitor reported this a resident spoke up and reported a nurse who is mean and hateful and this nurse had to shut up and quit talking so much. The NA said that is her personality. There is one employee that is hateful as the devil; when one resident asked for a drink and another asked if there was church tonight; she yelled and was hateful to both residents. Please address this issue with your staff. 2) This surveyor was provided a copy of an in-service for Ethical behavior and Unethical behavior conducted on 05/16/18 by the Administrator. 3) No further statements could be located. This allegation of abuse/neglect was not reported until after this Surveyors inquiry. Reported on 06/06/18 to the required agencies. No evidence was found or provided to support the facility conducted a thorough investigation or put interventions in place to protect the resident. j) Resident #114 1) Review of Resident #114's medical records found the resident was admitted on [DATE]. Care Plan initiated; Resident is a 53yr. old female-Diagnosis: [REDACTED]. Staff supervises meals, assists as needed. She is noted to take food from other resident's trays. Easily agitated. Diet Regular NAS with lidded cups for safety. Weight 102# --below IBW range (123#-149#) She feeds herself meals--often uses her fingers to eat --likes sweets and snack foods. No teeth or dentures. 2) Progress notes found the following incident/altercations involving resident-to-resident: --10/18/2017 at 08:28 - Resident noted to be up walking around day lounge throwing food on the floor and taking food from other resident's trays. --10/19/2017 at 18:00 - Resident up and ambulating in day lounge throwing her shoes across room pushing furniture against resident's wheelchairs. staff sits down with resident to assist with meal resident then gets up and proceeds to remove food from her brother's tray. when attempting to redirect resident begins hitting self in head and slamming fists on wall, offered activities, fluids and snacks with staff to monitor for safety. --11/6/2017 at 18:00 - Another resident was calling out to resident and calling her names. Resident became agitated and grabbed other resident's hair and pulled hard. Residents were separated by staff. Vital signs unable to be obtained due to resident was agitated. --11/9/2017 at 21:46 - Late Entry: Note: resident has been noted to be u (TRUNCATED)",2020-09-01